Patient Resources

Forms

Keller Army Community Hospital 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)

DOD Forms

Defense Health Agency Forms

TRICARE Forms

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