Start here if you have been told to submit DD Form 2871. First, know what you are filling: Request to Restrict Medical and Dental Information. The document is titled DD Form 2871, Request to Restrict Medical or Dental Information, December 2003.
Then look at the edition date: not stated, publisher status not stated. After that, ask whether the form covers your situation. It almost certainly does regardless of your branch — DD forms run Department-wide rather than through a single service.
After that, turn to timing. The requirement comes from not stated; the form is maintained by not stated. Local implementing instructions fill in the dates, so check with the office that will receive your copy.
Before you download, pick your approach — editable file or printed page. What follows covers the formats first, then the entries, then what you do afterward.
Now fill it in. Work from the top of the page downward, and do not jump ahead — the identifying block comes first, the substance of your entry second, the certification last. Later boxes often depend on what you put at the top.
Before your first entry, look at the corner of the page and compare the printed date with not stated. If they do not match, stop and download again. Old copies circulate in shared drives for years, and a DD form is revised centrally for every service at once, so a superseded blank may not carry the fields your reviewer expects.
Look up an unclear item on the form face before anywhere else, then in not stated. Should the two texts conflict, the directive is the one you follow.
Download the form
Step one is picking the format. You have PDF to choose from, across 2 pages, with approximately 28 fields to complete.
Take the pdf if you are unsure. Then check which kind you have: if the boxes highlight when you click them, you have a fillable pdf and can type straight into it, and your entries save with the file. If nothing highlights, you have a printable pdf — send it to a printer and use black ink.
Prefer typing over writing. Your form will likely be scanned and emailed onward, and typed text reproduces at every stage while pen strokes fade or blur. When you do write, print in capitals so the receiving clerk can read it.
Before you take the xfdl file, make sure you can open it. Install IBM Lotus Forms Viewer or an equivalent client first, because your pdf reader will refuse the file. Then download and complete it as normal.
You will not be charged for any of these; the whole set is free. Before you start entering data, save the file to your computer and open it there. Fields behave far more reliably in a desktop reader than in a browser preview.
What the form asks for
- Section 1 - Patient Data. 1. Name (last, first, middle initial).
- 2. Date of birth (4 digit year, 2 digit month, 2 digit day).
- 3. Social Security/Identification Number.
- 4. Period of treatment: From - to (4 digit year, 2 digit month, 2 digit day).
- 5. Type of treatment. Press space bar to mark X in first box if outpatient, second box if inpatient, or third box if both.
- 6. Request/Restriction is directed to the TRICARE Health Plan or the following physician/facility: a. Name of physician, facility, or TRICARE health plan.
- 6.b. Address (street, city, state and zip code).
- 6.c. Telephone (include area code).
- 6.d. Fax (include area code).
- 7. Purpose of restriction (optional).
- 8. Requested dates of restriction. a. Start (4 digit year, 2 digit month, 2 digit day).
- 8.b. End date (4 digit year, 2 digit month, 2 digit day).
- 9. Specify medical information to be restricted (use back for additional space).
- Section 3 - Please read and sign below. 10. Signature of patient/guardian.
- 11. Relationship to patient (if applicable).
- 12. Date (4 digit year, 2 digit month, 2 digit day).
- 13. X first box if approved, second box if disapproved.
- Mark X if response is attached.
- 14. Signature of approving official.
- 15. Imprint of patient identification plate when available.
- Sponsor name.
- Sponsor rank.
- FMP/Sponsor SSN.
- Branch of service.
With the form finished, route it to the office named in not stated or in your organization's own instruction. Keep a copy first. People rarely regret having one and frequently regret not having one.
If the form points you to another document, you can find it by number alone. DD numbering runs across the whole Department, so you do not need to work out which service issued it — one number, one form, everywhere.
Be careful when a procedure pairs this form with a service form. Read the prefix, not just the digits. Service forms answer to a service proponent, while DD forms answer to not stated or an equivalent Department office, and the two sequences were never aligned. Grabbing the wrong prefix gets you a form that has nothing to do with your task.
Do not archive this file and reuse it in a year. Forms are reissued as directives are revised, as data requirements shift, and as statutory notice text is amended. Your protection is simple: download fresh each time and confirm the edition date.
Before you go, note what is not covered here. You have the blank form and instructions for completing it; you do not have legal guidance, and no statement on this page determines what any office will do with your submission. Direct those questions to not stated, to the personnel office that serves you, or to the office designated in not stated.
Questions and answers
- What is DD Form 2871?
- DD Form 2871, Request to Restrict Medical or Dental Information, December 2003
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?