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Fillable lm-3 Form: What You Should Know

The attached DD Form 2138, “Health Care Documentation to Be Made Available Upon Request for the Use of the Information.” This form serves as your Authorization for a health care provider to provide your medical  diary, medical record, and medical records on an official, confidential, and proprietary basis to the  Provider of record. It does not give consent for the release for the use of your personal medical  record to your medical provider for any other purposes. 3. The attached DD Form 2482, “Dental Records for the Uniformed Services.” This form  serves to provide dental records for a uniformed service member for whom a military dentist is necessary. It is not  authorized for the release for the use of a physician to any other person or entity. 4. The attached DD Form 2766, “Disclosure of Military Medical Records to TRI Care.” This form is required by the  Service to provide a copy of each record for a TRI care patient. It is required to keep copies of all records. 5. The attached DD Form 2770, “Disclosure of Military Medical Records to TRI Care.” This form is required by the  Service to provide a copy of each record for a TRI care patient. It is not authorized for the release for the use  of a physician to other health care providers for which it does not possess any necessary medical services. Note: The DD Form 2770  is a legal record that you may submit to your civilian legal counsel. It serves to provide the Fox  Army Health Center (FAC) and Medical Care Providers with access to your medical records for purposes of  disclosure and/or inspection when requested by FAC and/or TRI Care. 6. The attached DD Form 2870, “Privacy Act Request for Privacy Act Protection.” 7. “FAC/TRI CARE/TRI CARE Program Records”: Your medical records are maintained in Trocar files that are protected under the “FAC/TRI CARE/TRI CARE Program Records” classification. This form must be submitted by the provider(s) requesting  your medical records, or they may request disclosure of such records from FAC upon written inquiry.  8. “Disclosure of Military Records to DOD Medical Care Providers, TRI Care” 8.

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