Transcription of DEPARTMENT OF DEFENSE OMB No. 0720-0022 OMB …
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DEPARTMENT OF DEFENSE OMB No. 0720-0022 OMB …
DD FORM 2813, OCT 2013 DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN FORCES DENTAL EXAMINATION PREVIOUS EDITION IS OBSOLETE. OMB No. 0720-0022 OMB approval expires Aug 31, 2016 PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. AUTHORITY: 10 136; 10 1074f; DoD Directives , , , and ; DoD Instruction ; and 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 , the DoD Health Information Privacy Regulation. Information may also be used and disclosed in accordance with 5 552a(b) of the Privacy Act of 1974, as amended, which 1.
Temporomandibular disorders or myofascial pain dysfunction requiring active treatment. (4) If you selected Block (3) above, please indicate the condition(s) you identified in this patient if they appear above, or br iefly describe the condition(s) below: (5) Were X-rays consulted? YES . NO IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD) 7. DENTIST'S NAME
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