Raymond W. Bliss Army Health Center > Patient Resources > Forms

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RWBAHC Required Patient Administration Forms

DHA HIPAA Complaint Form
DD Form 2870, Authorization For Disclosure of Medical or Dental Record
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.

Download Form
RWBAHC NOPP Form 425
Acknowledgment of Military Health System Notice of Privacy Practice (N.O.P.P)

Download Form
RWBAHC WS 130 Line of Duty Information Sheet
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.

Download Form
RWBAHC WS 131 Patient Registration Form
Download Form

Mon - Fri: 7:00 a.m. - 4:00 p.m.

520-533-9061

520-533-2507 / FAX: 520-533-5246

520-533-1856

520-533-0447

2240 E. Winrow Ave.
Ft. Huachuca, AZ 85613

Don’t forget to keep your family’s information up to date in DEERS!