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)

Defense Health Agency Forms

TRICARE Forms

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