Dd Form 2807-2 - Accessions Medical Prescreen Report Page 6
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7LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION V - APPLICANT VALIDATION, AUTHORIZATION AND SIGNATURE
STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES IN SECTION V (BELOW)
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I (we) , the undersigned:
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Certify the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me
to conceal or falsify any information about my physical and mental history.
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Authorize and understand that a physical examination is part of the accession evaluation, may require several visits to the Military
Entrance Processing Station (MEPS), and that I will have blood work and/or other medical tests, procedures and/or specialty
consultations performed as part of my processing. I understand that the results of the examination, tests, and consults will be
reviewed and considered as part of my application file and are not performed as part of an individual healthcare treatment plan.
The MEPS medical staff are not my healthcare providers. If I do not receive notice of an abnormal test or consult, I am not to
assume that the results are normal. Furthermore, if any test or consult results are abnormal, I am responsible for obtaining those
results from the MEPS and for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS to
discuss medical results, it is my responsibility to take quick action to return to the MEPS to speak with the Chief Medical Officer
(CMO). Any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare
provider(s).
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Understand that I must provide required documentation regarding my health history which, upon my accession, will become part
of my Service member lifecycle medical treatment record.
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Authorize the Department of Defense (DoD) to request holders of medical/behavioral health data (including but not limited to
healthcare providers, clinics, hospitals, insurance companies, pharmacy benefit managers, pharmacies, health information
exchanges, and federal and state agencies) to release to the DoD medical authority a complete transcript of my health data for
purposes of processing my application for Military Service. I also authorize holders of my health data to report to the DoD
whether any data they hold or have held about me has been amended or restricted. I agree that all personal information or data
disclosed by myself or others on my behalf with my consent during this process may be further disseminated as needed during the
accession process and that my medical information is no longer protected by federal Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rules.
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Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary
proceedings. Under the Family Educational Rights and Privacy Act (FERPA) USMEPCOM is authorized to receive all my
education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.
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Understand that I have the right to refuse to sign this authorization but also understand that failure to do so may cause me to be
found disqualified for further processing.
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Understand this authorization will expire two years from the date of the signature below or sooner if written request is received by
USMEPCOM Staff Judge Advocate’s Office. I have the right to revoke this authorization in writing, except to the extent that the
DoD has acted in reliance on this information.
1. APPLICANT
a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT,
SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED (YYYYMMDD)
3. RECRUITING REPRESENTATIVE:
(If a representative was used)
I certify all information is complete and true to the best of my knowledge.
b. RECRUITER
a. NAME (Last, First, Middle Initial)
c. SIGNATURE
d. DATE SIGNED (YYYYMMDD)
IDENTIFICATION NUMBER
DD FORM 2807-2, MAR 2015
Page 6 of 7 Pages
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