Dd 2813 Dental PDF Template

Dd 2813 Dental PDF Template

The DD 2813 Dental Form serves as a vital document for assessing the dental health of active duty, reserve, guard, and civilian members of the U.S. Armed Forces. This form is essential in determining an individual’s readiness for military deployment based on their oral health status. Completing this form accurately can help ensure that service members are fit for duty without immediate dental care access.

To fill out the DD 2813 Dental Form, click the button below.

Overview

The DD Form 2813 serves an important role in assessing the dental health of military personnel, including active duty members, reservists, and civilian forces. This form is essential for determining a service member's readiness for deployment. Filled out by a dentist, it captures crucial patient information, such as the service member's name, DoD ID number, and branch of service. Through an examination, the dentist evaluates oral health and marks the level of dental conditions observed. There are specific categories ranging from good oral health with no anticipated need for treatment, to conditions that could lead to dental emergencies within a year. The form also allows for the inclusion of X-ray data, reinforcing the importance of thorough evaluations. Furthermore, it emphasizes the need for clear communication about the findings, ensuring that service members receive the appropriate care to maintain optimal dental health during their service. While completion of the form is voluntary, it carries potential implications for deployment readiness if not filled out correctly.

Dd 2813 Dental Preview

CUI when filled

DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN FORCES DENTAL EXAMINATION

OMB No. 0720-0022 OMB approval expires 20230131

The public reporting burden for this collection of information is estimated to average 3 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 whs.mc-alex.esd.mbx.dd-dod- informationcollections@mail.mil. 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 FORM TO THE ABOVE ORGANIZATION.

AUTHORITIES: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Chapter Ch. 55, Medical and Dental Care; 10 U.S.C.

1097a, TRICARE Prime: Automatic Enrollments; Payment Options; 10 U.S.C. 1097b, TRICARE Prime and TRICARE Program: Financial Management; 10 U.S.C.

1079, Contracts for Medical Care for Spouses and Children: Plans; 10 U.S.C. 1079a, TRICARE Program: Treatment of Refunds and Other Amounts Collected Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); 10 U.S.C. 1086, Contracts for Health Benefits for Certain Members, Former Members, and Their Dependents; 10 U.S.C. 1095, Health Care Services Incurred on behalf of Covered Beneficiaries: Collection From Third-party Payers; 42 U.S.C. 290dd-2, Confidentiality Of Records; 42 U.S.C 42 U.S.C. Ch. 117, Sections 11131-11152, Reporting of Information; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD 6025.18-R, DoD Health Information Privacy Regulation; and E.O. 9397 (SSN).

PURPOSE: To collect patient information necessary to determine the patient’s readiness to participate in a military deployment.

ROUTINE USES: Information in your records may be disclosed to other components within the Department of Defense to determine your readiness to participate in a military deployment. Information in your records may also be disclosed to private physicians and Federal agencies, including the Departments of Veterans Affairs, Health and Human Services, and Homeland Security in connection with your medical care; other federal, state, and local government agencies to determine your eligibility for benefits and entitlements and for compliance with laws governing public health matters; and government and non-government third parties to recover the cost of healthcare provided to you by the Military Health System. Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, “Military Health Information System,” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/ SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary. However, failure to provide the information requested may result in delays in assessing your dental health needs for military service and/or for possible deployment.

1. SERVICE MEMBER'S NAME (Last, First, Middle Initial)

2. DoD ID Number

3. BRANCH OF SERVICE

 

 

 

4. UNIT OF ASSIGNMENT

5. UNIT ADDRESS

 

6.EXAMINATION RESULTS Dear Doctor,

The individual you are examining is an Active Duty/Guard/Reserve/Civilian member of the United States Armed Forces. This member needs your assessment of his/her dental health for worldwide duty. Please mark (X) the block that best describes the condition of the member, using as a suggested minimum a clinical examination with mirror and probe, and bitewing radiographs. This form determines fitness for prolonged duty without ready access to dental care and is not intended to document comprehensive dental needs.

(1)Patient has good oral health and is not expected to require dental treatment or reevaluation for 12 months

(2)Patient has some oral conditions, but you do not expect these conditions to result in dental emergencies within 12 months if not treated (i.e., requires prophylaxis, asymptomatic caries with minimal extension into dentin, edentulous areas not requiring immediate prosthetic treatment).

(3)Patient has oral conditions that you do expect to result in dental emergencies within 12 months if not treated.

Examples of such conditions are: (X the applicable block or specify in the space provided)

(a)Infections: Acute oral infections, pulpal or periapical pathology, chronic oral infections, or other pathologiclesions and lesions requiring biopsy or awaiting biopsy report.

(b)Caries/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective restorations or temporary restorations that patients cannot maintain for 12 months.

(c)Missing Teeth: Edentulous areas requiring immediate prosthodontic treatment for adequate mastication, communication, or acceptable esthetics.

(d)Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis, periodontal abscess, progressive

mucogingival condition, moderate to heavy subgingival calculus, or periodontal manifestations of systemic disease or hormonal disturbances.

(e)Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.

(f) Other: Temporomandibular disorders or myofascial pain dysfunction requiring active treatment.

(4) If you selected Block (3) above, please indicate the condition(s) you identified in this patient if they appear above, or briefly describe the condition(s) below:

(5) Were X-rays consulted?

IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)

7.DENTIST'S NAME (Last, First, Middle Initial)

8. DENTIST'S TELEPHONE NUMBER (Include Area Code)

9. DENTIST'S SIGNATURE

9. DENTIST'S LICENSE NUMBER

10. DATE OF EXAMINATION (YYYYMMDD)

DD FORM 2813, NOV 2021

PREVIOUS EDITION IS OBSOLETE.

Controlled by: DHA

CUI when filled

CUI Category: PRVCY

 

LDC: FEDCON

 

POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@mail.mil

File Properties

Fact Name Description
Form Purpose This form is designed to collect essential dental health information for military personnel to determine their readiness for deployment.
OMB Approval The form has an OMB approval number (0720-0022) and approval expires on January 31, 2023.
Routine Uses Information from the form may be shared within the Department of Defense and with other agencies to assess benefits eligibility and healthcare needs.
Voluntary Disclosure Providing information is voluntary; however, withholding it could delay assessments of dental health for military service and deployment.
Applicable Laws This form is governed by several laws, including Public Law 104-191 (HIPAA) and various sections of the U.S. Code relating to military healthcare.
X-Ray Information If X-rays are consulted, the date they were taken must be provided to aid in the assessment.
Dentist's Role A licensed dentist must perform the examination and provide their assessment in this document.
Document Control The form is controlled by the Defense Health Agency and has specific privacy guidelines under DoD regulations.
Previous Versions The current version (NOV 2021) replaces previous editions of the DD Form 2813.

Instructions on Utilizing Dd 2813 Dental

Completing the DD 2813 Dental form is an important step in assessing your readiness for military deployment. Follow these steps carefully to ensure that all necessary information is accurately captured.

  1. Write the service member's full name in the designated section (Last, First, Middle Initial).
  2. Enter the DoD ID number assigned to the service member.
  3. Select the branch of service from the provided options.
  4. Input the unit of assignment for the service member.
  5. Fill in the unit address accurately.
  6. Complete the examination results section:
    • Indicate the dental health status by marking an 'X' in the appropriate block.
    • If block (3) is selected, briefly describe the identified oral conditions in the space provided.
    • Record whether X-rays were consulted and, if so, the date they were taken (YYYYMMDD).
  7. Provide the dentist’s full name (Last, First, Middle Initial).
  8. Include the dentist's telephone number with the area code.
  9. Sign the form in the designated area to confirm the examination's validity.
  10. Indicate the dentist's license number.
  11. Finally, enter the date of the examination (YYYYMMDD).

Important Facts about Dd 2813 Dental

What is the purpose of the DD 2813 Dental Form?

The DD 2813 Dental Form is used to collect important information about a patient’s dental health. It helps determine if a service member is ready to participate in military deployment. This assessment focuses on identifying any dental issues that may need attention before deployment.

Who needs to fill out the DD 2813?

This form is intended for Active Duty, Reserve, National Guard, and civilian members of the United States Armed Forces. A dentist will typically complete the form after examining the service member.

How does the form categorize dental conditions?

The form provides several categories regarding dental health. These include good oral health, minor conditions that may not lead to emergencies within 12 months, and conditions likely to cause emergencies if not treated. Dentists can check the appropriate box to indicate the patient's status based on their examination.

What information does the dentist need to provide?

The dentist must provide their name, contact details, license number, and signature. They will also indicate the date of the examination and whether X-rays were consulted during the assessment.

Is filling out the DD 2813 mandatory?

Filling out the DD 2813 is voluntary. However, not providing the requested information may lead to delays in assessing the service member’s dental health needs. This delay could affect their readiness for deployment.

How long does it take to fill out the DD 2813?

The estimated time to complete the DD 2813 is about three minutes. This includes reviewing the instructions and gathering any necessary information.

What happens if the dentist identifies a dental emergency?

If the dentist determines that a service member has an oral condition expected to result in emergencies within 12 months, they will mark the relevant box on the form. They may also provide additional details about the identified condition in the designated section of the form.

What laws govern the information collected in this form?

The collection of information on the DD 2813 is subject to various laws, including the Health Insurance Portability and Accountability Act (HIPAA). This ensures that patient information is handled securely and confidentially.

What should I do if I have questions about my dental examination?

If you have any questions regarding your dental examination or the DD 2813, you should contact your dentist. They can provide you with further clarification and guidance based on your specific situation.

Where do I submit the completed DD 2813?

Do not send the completed form to the Department of Defense address listed in the instructions. Instead, submit it to the appropriate authority as directed by your command or military healthcare provider.

Common mistakes

Completing the DD Form 2813, which serves as a dental examination for military personnel, is crucial for ensuring readiness for deployment. However, several common mistakes can hinder the process and affect the overall assessment.

First, one frequent error is failing to include accurate personal information, particularly the service member's name and DoD ID number. These details verify the individual's identity and military affiliation. Omissions or inaccuracies can lead to delays in processing and may prevent proper assessment of dental health needs.

Another mistake involves neglecting to specify the branch of service and the unit of assignment. Clear identification helps ensure that the examination is compliant with specific military standards and protocols relevant to the respective branch.

Additionally, many individuals overlook the importance of including the dentist's complete information, such as full name, license number, and contact details. Missing this information can pose challenges in following up on the exam results or addressing any subsequent questions.

A critical part of the form involves the examination results. Some examiners do not clearly mark the appropriate block that reflects the patient's dental condition. This can lead to misinterpretation of the patient's needs and readiness. Clear and specific descriptions are essential for accurate future planning and treatment.

Furthermore, the failure to indicate whether X-rays were consulted, along with the date taken, can compromise the thoroughness of the assessment. If the dental examination is based solely on visual inspection, critical underlying conditions may go unnoticed.

Lastly, individuals sometimes assume that the DD 2813 can be returned to the organization mentioned in the document. This assumption can result in unnecessary processing delays, as the instructions explicitly state to not return the form to the indicated address.

Being mindful of these common pitfalls when filling out the DD Form 2813 can facilitate a smoother process and help maintain the dental health of service members as they prepare for their duties.

Documents used along the form

The DD 2813 Dental Form is essential for assessing a service member's dental readiness for military duty. Alongside this form, there are several other documents that often accompany it. Each of these documents serves a specific purpose in ensuring comprehensive dental care and administrative efficiency in military settings.

  • DD 2766: This document is a record of a service member’s medical history. It includes information about allergies, medications, and previous treatments. It helps healthcare providers make informed decisions about a patient's care.
  • SF 600: Also known as the Chronological Record of Medical Care, this form documents all medical visits and treatments received by the service member. It provides a chronological overview of a patient’s medical history.
  • DD 2870: The Authorization for the Disclosure of Medical or Dental Information form allows service members to authorize the release of their health information to specific individuals or organizations, promoting transparency in their healthcare.
  • DD Form 2282: This form documents any dental procedures performed on the service member, such as fillings or extractions. It is crucial for recording ongoing dental care needs.
  • DA Form 705: This form is used to assess a soldier's physical training and readiness. While not directly related to dental care, it is part of the overall health evaluation process in the military.
  • DA Form 5500-R/DA Form 5501-R: These forms are used for recording body composition data of service members. Maintaining a healthy weight is vital for overall fitness, which indirectly relates to dental health due to physical fitness requirements.
  • CHAMPUS Claim Form: This document is used for filing claims for dental care through the Civilian Health and Medical Program of the Uniformed Services. It ensures that service members receive their entitled dental benefits.
  • Private Health Insurance Claim Form: Service members with private insurance may need to file a claim for dental services. This form includes details of the treatment received and costs incurred.

In summary, the documents that are often used alongside the DD 2813 Dental Form facilitate a systematic approach to healthcare for service members. Each form plays a vital role in ensuring that dental and overall health needs are met, ultimately supporting the readiness and well-being of military personnel.

Similar forms

  • DD Form 2807-1: This document, known as the "Report of Medical History," collects medical histories of service members. Like the DD 2813, it focuses on assessing a service member's health status, specifically in relation to military duty fitness.
  • DD Form 2812: The "Dental Health Questionnaire" gathers information about a member's past dental treatments and conditions. It serves a similar purpose by aiding dental professionals in determining readiness for deployment, similar to the dental examination results specified in the DD 2813.
  • DD Form 2173: Commonly referred to as the "Statement of Medical Examination and Duty Status," this form evaluates the medical condition and duty status of a service member. The assessment aims to maintain the same readiness goals as those outlined by the dental examination form.
  • SF 600: This "Chronological Record of Medical Care" records various medical encounters and treatments. Its purpose overlaps with the DD 2813 in terms of tracking the overall health status of military personnel to ensure they are fit for service.
  • DA Form 3349: Known as the "Physical Profile Serial Report," this form details a soldier’s physical capabilities. It aligns with the objectives of the DD 2813 by providing essential information about one’s health that impacts military assignments and deployments.

Dos and Don'ts

When completing the DD 2813 Dental form, there are important considerations to ensure accuracy and efficiency. Below is a list of guidelines to follow, including actions to take and what to avoid.

  • Do ensure all personal information is accurate. Double-check the service member's name, DoD ID number, and other identifying details.
  • Do accurately assess dental health. Mark the block that best describes the member's dental condition based on a thorough examination.
  • Do include the dentist's full name and contact information. This facilitates communication regarding the patient's care.
  • Do provide dates for any X-rays taken. If applicable, include the date in the specific format requested.
  • Don’t leave any sections blank. Ensure that all applicable parts of the form are filled out to avoid delays.
  • Don’t misrepresent the dental condition. Providing incorrect assessments can lead to inadequate care.
  • Don’t ignore the instructions outlined on the form. Following instructions can help in smoother processing of the form.
  • Don’t forget to sign the form. Ensure the dentist's signature is present, as it is a required validation.

Misconceptions

Understanding the DD 2813 Dental form is crucial for many service members, but common misconceptions can lead to confusion. Here are nine misconceptions, along with their clarifications:

  1. This form only applies to active duty service members. Many believe the DD 2813 is exclusively for active duty personnel. However, it is also applicable to reserve and guard members, as well as certain civilian forces.
  2. Completing the form is mandatory. While it is highly recommended for dental assessments regarding military readiness, the disclosure of information is voluntary. Choosing not to provide information could delay dental health evaluations, but it is not a legal requirement.
  3. This form is only used for emergency dental care. Some people think that the DD 2813 is only relevant in emergencies. In reality, it assesses the overall dental health of a service member to determine readiness for deployment, regardless of any urgent needs.
  4. It captures comprehensive dental needs. There is a misconception that the DD 2813 is designed to document all dental care needs. Instead, it primarily focuses on determining fitness for service and readiness for duty.
  5. All dental conditions must be fixed before deployment. Some service members assume that every dental issue must be resolved before they can deploy. The DD 2813 allows for the identification of non-emergency conditions that may not require immediate treatment but should be monitored instead.
  6. The dentist solely fills out the form. A common belief is that only the dentist is responsible for completing the DD 2813. In actuality, both the service member and the dentist contribute information to ensure accuracy.
  7. No follow-up is required after submission. Many assume that once the DD 2813 is submitted, nothing else needs to be done. However, if conditions are identified that could lead to emergency situations, follow-up care may be necessary.
  8. All information submitted is confidential. While protected health information (PHI) is generally kept confidential, it can be shared with various agencies as needed, particularly for the assessment of readiness and benefits.
  9. This form has no expiration. Some people believe the DD 2813 remains valid indefinitely. In fact, the form has specific validity periods, and regular updates or new assessments may be required, especially before deployment.

By understanding these misconceptions about the DD 2813 Dental form, service members can better navigate their dental health assessments and deployment readiness.

Key takeaways

Filling out the DD 2813 Dental form is crucial for service members seeking assessment of their dental health in relation to military duties. Here are some key takeaways to ensure the form is completed accurately and effectively.

  • Understand the Purpose: The DD 2813 form collects essential dental health information to determine a member's readiness for deployment. Completing it accurately helps facilitate timely evaluations and decisions.
  • Provide Complete Information: Ensure all sections of the form are thoroughly filled out, including personal details such as name, DoD ID number, and branch of service. Incomplete forms may lead to delays in dental readiness assessments.
  • Follow Examination Guidelines: The dentist should conduct a clinical examination using recommended tools like a mirror, probe, and bitewing radiographs. The choices outlined in the examination results section must reflect the member's true dental condition.
  • Recognize the Disclosure Implications: Although providing information is voluntary, not completing the form can delay important assessments. Personal health information may be shared within the Department of Defense and with specific healthcare providers as necessary.

Understanding these points can help streamline the process of dental assessments, ensuring service members maintain their readiness for duty.

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