DD Form 3217 MILITARY ONESOURCE THIRD-PARTY RECORDS RELEASE REQUEST

MILITARY ONESOURCE THIRD-PARTY RECORDS RELEASE REQUEST

OMB No. 0704-MTPR
Expires TBD

The public reporting burden for this collection of information is estimated to average ## hours/minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters
Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall
be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 5 U.S.C. 552, Freedom of Information Act, as amended; 5 U.S.C. 552a, Privacy
Act of 1974, as amended; 32 CFR part 286, DoD Freedom of Information Act (FOIA) Program; 32 CFR part 310, Protection of Privacy and Access and Amendment of
Individual Records Under the Privacy Act of 1974; DoD Directive 1322.18, Military Training; DoD Instruction (DoDI) 1342.22, Military Family Readiness; DoDI 6490.06,
Counseling Services for DoD Military, Guard and Reserve, Certain Affiliated Personnel, and Their Family Members; and DoDI 1322.26, Distributed Learning (DL); DoD
Directive, 5400.07, DoD Freedom of Information Act (FOIA) Program; DoD Instruction 5400.11, DoD Privacy and Civil Liberties Programs; DoD Manual 5400.07, DoD
Freedom of Information Act (FOIA) Program; DoD 5400.11–R, DoD Privacy Program; and Executive Order 9397 (SSN), as amended.
PURPOSE: To process, track, and report access requests and administrative appeals for Military OneSource records under the FOIA, and access and amendment requests
and administrative for Military OneSource records appeals under the Privacy Act.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, as amended. Pursuant to 5 U.S.C. 522a(b)(3), records
may be disclosed as a routine use Tto contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative
agreement, or other assignment for the federal government when necessary to accomplish an agency function related to this system of records. A complete list of routine
uses may be found in the applicable System of Records Notice, DoD–0008, Freedom of Information Act and Privacy Act Records (FOIA/PA Records) at: https://
www.federalregister.gov/d/2021-27710
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in your request not being processed.

HOW TO USE THIS FORM
Fields on this form should be used to request information maintained in the Military OneSource Case Management System (DPR 45: Military
OneSource Business Operations Information System) as outlined below.
A copy of this form should be submitted for all individuals who are the subject of, or a participant listed within, the records. Requests for Military
OneSource Records should be submitted directly by the subject of the record, wherever possible.

NEEDS DD67

Part 1 – Request Details

Section 1 – Subject of the Records Request

The individual to whom a record pertains is described as the subject of record—i.e., the individual whose record is being requested. To facilitate the
identification of the record subject and the processing of your request, please complete any of the blocks below if the information is known.
Other Names Previously Used:

Full Name (First, Middle, Last):

Current Address:

Date of Birth (YYYYMMDD):

Branch of Service:

Phone Number:

Email Address:

Section 2 – Nature of the Request
Military OneSource provides a large array of services. To best facilitate a timely and accurate response, please provide any details about the types of
Military OneSource records sought. For more information on these services, visit: https://www.militaryonesource.mil/about-us/
Description of the records sought:

Section 3 – Requestor Information
Full Name (First, Middle, Last):

Current Address:

Phone Number:

Email Address:

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What is your relationship to the subject?
I am a deceased subject's next-of-kin. (Next-of-kin may be any of the following: unmarried/surviving spouse, father, mother, son, daughter, sister,
or brother. (Please attach proof of death of the subject, such as a death certificate or probate documents filed in court.)
I am an attorney or accredited representative, acting on behalf of the subject of records. (Please attach proof of legal authorization or consent,
such as a signed court order or the signed written consent of the subject which clearly authorizes the release of non-medical counseling or other
Military OneSource records, in accordance with the Privacy Act of 1974.1)
Other (Please explain and provide all appropriate documentation.):

Part 2 – Signatures and Consent
This request must be accompanied by either a signed unsworn declaration, or notarized statement, for each of the below sections, as appropriate. To
facilitate DoD’s validation of the request, please provide either a physical (wet ink) signature or digital signature associated with a DoD Common
Access Card. A typed name alone will not be considered a valid signature.
Section 4 – Requestor Signature
If executed within the United States, its territories, possessions, or commonwealths:
I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct, and that I have the legal authorization or consent to
obtain the records of the subject named in Section 1.
Executed On (YYYYMMDD):

Printed Name:

Signature of Subject:

If executed outside the United States:
I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and
that I am the person named above in Section 1 and requesting the release of my records.

NEEDS DD67

Executed On (YYYYMMDD):

Printed Name:

Signature of Subject:

Office of the Secretary of Defense/Joint Staff Freedom of Information Act Requester Service Center
155 Defense Pentagon, Washington DC 20301-1155, or Fax: 571-372-0500.
http://www.esd.whs.mil/FOID/foi

1 Per DoDI 6490.06,”Counseling Services for DoD Military, Guard and Reserve, Certain Affiliated Personnel, and Their Family members,” Military OneSource (MOS) and Military Family
Life Counseling (MFLC) Program counselors provide nonmedical, short-term, solution-focused counseling and briefings for circumstances amenable to brief intervention. Note, as MOS
and the MFLC Program are not healthcare programs, the records from these programs are not subject to DoDI 6025.18, “Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule Compliance in DoD Health Care Programs” and consent for release of HIPAA records does not apply.

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