Filing a complaint with the Raymond W. Bliss Army Health Center (RWBAHC) is voluntary. However, without the information requested, RWBAHC may be unable to proceed with your complaint. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of information outside the Military Health System/TRICARE for purposes associated with health information privacy compliance and as permitted by law. It is illegal for a covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the HIPAA Privacy Rule.

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DD Form 2870, Authorization For Disclosure of Medical or Dental Record: This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.

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RWBAHC Form 429 Patient Request for Medical Record Amendment allows a patient the means to request an amendment of their medical information in accordance with DODM 6025.18.

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Acknowledgment of Military Health System Notice of Privacy Practice (N.O.P.P)

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The RWBAHC WS 130 Line of Duty Information Sheet is for use when you've been inured or become ill in the line of duty.

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