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Patient Resources

Forms

DHA FORM 116 - Pediatric and Adult Influenza Screening and Immunization Document
Active Duty Dental Claim Form (531KB .PDF)
United Concordia's network dentists will file a claim on your behalf. If you are approved to utilize a non-network dentist, you may be required to submit your own claim form. United Concordia's network dentists will file a claim on your behalf.

Download Form
Child Central Auditory Processing Questionnaire
WAMC Form 5004 - Child Central Auditory Processing Questionnaire

Download Form
Authorization for Disclosure of Medical or Dental Information
DD form 2870 (Authorization for Disclosure of Medical or Dental Information)

Download Form

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