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TRICARE Dental Program Enrollment/Change Authorization

TRICARE Dental Program Enrollment/Change Authorization Form Privacy Act Statement This statement serves to inform you of the purpose for collecting personal information required by the TRICARE Dental Program (TDP) and how it will be used. AUTHORITY: 10 Chapter 55, Medical and Dental Care; 32 CFR , TRICARE Dental Program ; and 9397 (SSN), as amended. PURPOSE: To collect information from you to manage your enrollment in the TDP, administer your benefits, and pay for the services you receive. ROUTINE USES: Your records may be disclosed to providers of care and other business entities on matters relating to eligibility, claims pricing and payment, fraud, quality assurance, Program integrity, and the coordination of benefits. Your records may also be disclosed outside of the Department of Defense (DoD) in accordance with the DoD Blanket Routine Uses published at Caution- and as permitted by the Privacy Act of 1974, as amended (5 552a(b)).

Please review these instructions before submittingthe Enrollment/Change Authorization. For help completing the Enrollment/ Change Authorization call: CONUS: 844-653-4061 OCONUS: UCCI: 844-653-4060 Send Enrollment/Change Authorization with payments to: UCCI TRICARE Dental Program, P.O. Box 645547, Pittsburgh, PA 15264-5253. SECTION I

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