Service members may use civilian dentist and a dd 28 to meet annual dental requirement 2 out of 3 years. They should also take a copy of the dental form, dd28, to their dentist at the time of their appointment. Affidavit in support of motion for temporary relief with children. When revisions to these publications are published, those revisions will aspersed this letter. Dd form 28 active duty reserve forces dental examination. Dd form 28 applies to members of the examinations performed by civilian dentists. The active duty dental program privacy act statement. Periodic health update general instructions for completing. The advanced tools of the editor will guide you through the editable pdf. Use this stepbystep guide to complete the dd form 28 oct 20 swiftly and with perfect accuracy. All forms and provider instructions are included in a single pdf file, phu appointment documents, which can be found on the ccmis website under formsmedical.
Directives division washington headquarters services. Download a blank fillable dd form 28 department of defense active dutyreserve forces dental examination in pdf format just by clicking the download pdf button. The examination form often incorrectly referred to as the da form. The dd 28 or the military dental form is completed by the dental treatment facility dtf or civilian provider and the gathered information is stored within personnel medical files. This form has not been set up to work with a texttospeech reader. The information in this letter will be incorporated into ar 4035 and ar4066.
Dd form 214, certificate of release or discharge from active duty is a form issued by the department of defense dod and provided to every veteran discharged, retired or separated from active duty in the armed forces of the united states the form sometimes incorrectly referred to as the da form 214 was last revised in august 2009. Dd form 2870, dec2003 united states army infantry school ctmc fort benning, ga 31905 title. Omb no 07200022 dd form 28 department of defense active dutyreserve forces dental examination form approved omb no. Dd form 28, active duty reserve guard civilian force dental examination for the annual dental examination. If a beneficiary would like to nominate their dentist for participation with united concordia, heshe should submit the nominate my dentist form. It should be downloaded and given to the dental provider to complete. Coa 1 hand deliver the form to medical or your unit health monitor coa 2 email the form to medial.
The form is used by military physicians to determine if an applicant is fit for extended service away from dental help. This form is meant to determine fitness for prolonged duty without ready access to dental care and is not intended to address the members comprehensive dental needs. Pdf, reserve component survivor benefit plan rcsbp election certificate. This version of the adobe acrobat is not compatible with the apd website. Page 2 of form dd2808 name and serno at top of page must be completed. The dd form 28, dod active dutyreserve forces dental examination, will be used to assist the tdpenrolled national guardreserve forces in documenting member dental health. If you believe a dentist or entity has received insurance money through the submission of a false claim, you should. If you would like to nominate your dentist for participation with united concordia, please submit the nominate my dentist form. This form is used to help active duty and national guard and reserve members in documenting dental health for worldwide duty.
Active dutyreserve forces dental examination the government requires all. Fillable dd form 28 department of defense active duty. Pdf, data for payment of retired personnel dd form 26565. Print out the form and take it to your nonarmy dental provider. Dd74 dependency statement child born out of wedlock under age 21 dd448 military interdepartmental purchase request dd397 claim certification and voucher for death gratuity payment dd462 bond of person designated to act on behalf of. Active dutyreserve forces dental examination the government requires all active duty and reserve members receive an annual dental examination. Quick reference checklist occ health provider or private. 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. It is the soldiers responsibility to ensure that the form is sent to the proper place. Adobe reader or any alternative for windows or macos are required to access and complete fillable content.
This form should be completed by the dtf or civilian provider and will be used to assist the services in documenting member dental health. Dd form 28, active dutyreserve forces dental examination, october 20 author. Dd74 dependency statement child born out of wedlock under age 21 dd448 military interdepartmental. You are here home legal forms department of defense dd forms dd28 department of defense active dutyreserve forces dental examination. Dd form 28 completed by civilian dentist dd form 28 must be turned in to the servicing active duty dental facility to update the corporate dental system cds and dental records. Waiver of all life insurance coverage i followed the instructions on the back of part 1. This letter prescribes the use of a new form dd form 28 department of defense reserve forces dental examination. Army publishing directorate army publishing directorate. Dd form 28 printable fill out and sign printable pdf. This form is used to used to assist active duty and national guard and reserve members in documenting dental health for worldwide duty. Department of defense active duty reserveguardcivilian forces dental examination form dd form 28 this form is used to used to assist active duty and national guard and reserve members in documenting dental health for worldwide duty. At least once every 3 years, a military dental officer must provide the annual dental exam per reference b.
A dd form 28 is a department of defense form is used for gathering dental information for military members who will spend an extended period of time away from dental services. Medical services preventive dentistry and dental readiness. Dd form 2843, classified material destruction record, september 2001 author. Dd form 2870, authorization for disclosure of medical or. The way to complete the online dd form 28 printable on the internet. Dd form 28 department of defense active dutyreserve forces dental examination must show you as a dental class 1 or 2. The employees copy of this form, when completed by the employing office, together with the fegli program booklet fe 7621 or fe 7620 for u. Current dd28071 report of medical history no older than one year will be required for assimilation, permanent promotion, and long term training. Fillable and printable army dental examination form 2020.
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