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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.

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

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

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