Annual Verification

Record Category DATA ON INSIDE FRONT COVER OF THE DENTAL RECORD JACKET Below the pencil entries box, indicate the record category by enteringan “X” in the box marked “Dental Treatment Record.” Service and Status Immediately below the record category box, indicate the sponsor’s branch of military service by entering an “X” in the appropriate box. If the sponsor is not an active duty Navy or Marine Corps member, enter an “X” in the “Other” box and write the service and rank/rate on the line provided. Check remaining boxes in this section as applicable with additional comments as follows: Retired. Check box if applicable and indicate service and rank/rate on line provided. Family Member. Check box if applicable and indicate relationship to sponsor. Family Member Insurance. Check “Yes” or “No” regarding dental insurance the family member may have. (e.g. United Concordia Companies, Inc. (UCCI), DELTA, HUMANA, etc.) Blood Type. Indicate blood type of patient. The format printed on the inside of the jacket front cover (fig. 2-7) should be completed in pencil only. This information should be entered at the time of record check-in (receipt) and should be kept current at all times by erasing previous, outdated entries. Have member complete blocks that are applicable. Most blocks are self-explanatory. Imprint of DD 2005, Privacy Act Statement The Imprint of DD 2005, Privacy Act Statement form (fig. 2-8) is preprinted and located in front of the center page in the dental record jacket. It must be signed in black ink by the patient, the parent, or the guardian must sign if the patient is a minor. Disclosure Accounting Record The Disclosure Accounting Record (fig. 2-9) is preprinted and located on the back of the center page of the dental record jacket. It is self-explanatory and will be filled out as needed. Forensic Examination The Forensic Examination form is preprinted and located on the inside back cover of the dental record jacket. The instructions for completing the Forensic Examination Form are discussed in Dental Technician, Volume 2, Chapter 2, “Dental Examinations.” Annual Verification Record Retirement Tape The annual verification section is located on the right-hand side of the jacket and starts with the year 1996-2014. Leave this section blank. This block should not be completed for dental records. For records of non-military patients, a tentative record retirement date (retirement year) should be indicated on all dental records by attaching a colored tape in the box marked “Retired Year Tape” on the Figure 2-7.—Data on inside front cover of the dental record jacket. 2-13