Dental Health Summary Form for Relocation Clearance
The Dental Health Summary form is essential for assessing the dental health of family members of active duty military members. This form is needed for relocation and travel clearance. It is completed by either a civilian or military dental provider based on TRICARE enrollment.
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How do I fill this out?
Filling out this form requires specific patient details and results from a dental examination. Begin by entering the patient's name and the sponsor's social security number. Then, indicate the findings of the dental examination based on the defined criteria.
How to fill out the Dental Health Summary Form for Relocation Clearance?
1
Enter the patient's name and sponsor's SSN.
2
Complete the dental examination results section.
3
Mark the appropriate condition block based on the findings.
4
Indicate if x-rays were consulted and provide the date if applicable.
5
Sign and date the form as the dental provider.
Who needs the Dental Health Summary Form for Relocation Clearance?
1
Active duty military members require this form for their family members' dental assessment during relocation.
2
Family members of military personnel use this form to provide necessary dental health information.
3
Dentists and dental clinics use this form to report their findings on military family members.
4
TRICARE Dental Plan enrollees need to complete this form for specialist referrals.
5
Military dental treatment facilities rely on this form for proper patient management.
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2
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3
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What are the instructions for submitting this form?
To submit the completed Dental Health Summary form, send it via email to the dental office associated with your military treatment facility. You may also fax the completed form to the designated number for your unit. Ensure to keep a copy for your records and confirm receipt with the facility you're submitting it to.
What are the important dates for this form in 2024 and 2025?
Please ensure to submit the Dental Health Summary form as soon as the family relocation is confirmed. Key dates to remember include the beginning and end of your travel window in 2024 and 2025. This will ensure compliance with dental health regulations for active military families.
What is the purpose of this form?
The purpose of the Dental Health Summary form is to assess and document the oral health condition of family members of active military personnel. This assessment is crucial for ensuring that family members are fit for relocation and travel, where access to dental care may be limited. By accurately filling out the form, dental providers contribute to the readiness and health of military families.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient.
- 2. Sponsor SSN: The social security number of the military sponsor.
- 3. Family Member Prefix: Prefix indicating the relationship of the family member.
- 4. Dental Examination Results: Section to record the outcomes of the dental examination.
- 5. Dental Provider Name: The name of the provider completing the form.
- 6. Signature: The provider's signature verifying the information.
- 7. Date: The date the assessment and form completion took place.
What happens if I fail to submit this form?
Failure to submit the Dental Health Summary form may result in delays in the relocation process. This could hinder family members from accessing necessary dental care during their travel. It is crucial to complete and submit the form to avoid issues with military clearance.
- Travel Delays: Incomplete forms can lead to postponement of travel plans.
- Access to Care: Failure to submit may restrict access to dental services on relocation.
- Military Compliance: Non-compliance with military regulations concerning dental health may occur.
How do I know when to use this form?
- 1. Relocation Clearance: Essential for obtaining clearance prior to moving due to military orders.
- 2. Travel Health Check: Used to ensure family members are healthy for travel where dental care may be limited.
- 3. Routine Assessments: Serves as a routine check-up for dental health prior to family transitions.
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