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DENTIST S TELEPHONE NUMBER Include Area Code 10. DENTIST S SIGNATURE/STATE LICENSE NUMBER DD FORM 2813 OCT 2013 PREVIOUS EDITION IS OBSOLETE. 11. DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN FORCES DENTAL EXAMINATION OMB No* 0720-0022 OMB approval expires Aug 31 2016 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 Executive Services Directorate Information Management Division 4800 Mark Center Drive Alexandria VA 22350-3100 0720-0022. 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* PRIVACY ACT STATEMENT AUTHORITY 10 U*S*C. 136 10 U*S*C. 1074f DoD Directives 1404. 10 5101. 1 5136. 01 and 6490. 02E DoD Instruction 6025. 19 and E*O. 9397 SSN as amended* PRINCIPAL PURPOSE S To obtain information in order to record an assessment of an individual s dental health. ROUTINE USE S Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164 Health Insurance Portability and Accountability Act HIPAA Privacy and Security Rules as implemented by DoD 6025. 18-R the DoD Health Information Privacy Regulation* Information may also be used and disclosed in accordance with 5 U*S*C. 552a b of the Privacy Act of 1974 as amended which incorporates the DoD Blanket Routine Uses published at http //dpclo. defense. gov/privacy/SORNs/blanketroutineuses. html* Information from this system may be shared with other Federal and State agencies and civilian health care providers as necessary to provide medical care and treatment and to guide possible referrals. DISCLOSURE Voluntary however failure to provide the information may result in delays in assessing your dental health needs for military service and/or for possible deployment outside the United States and its territories and possessions. 1. SERVICE MEMBER S NAME Last First Middle Initial 2. SOCIAL SECURITY NUMBER 4. UNIT OF ASSIGNMENT 3. BRANCH OF SERVICE 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 is meant to determine fitness for prolonged duty without ready access to dental care and is not intended to address the member s comprehensive dental needs.

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