Privacy Act Statement

This statement serves to inform you of the purpose for collecting personal information required by the ADDP claim form and how it will be used.

AUTHORITY:

10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR Part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); DoDD 6490.02E, Comprehensive Health Surveillance; and E.O. 9397 (SSN), as amended.

PURPOSE:

To collect information necessary for completion of your dental readiness examination conducted by a dental provider and to collect information necessary for the dental provider to submit a claim for payment for the dental services provided to you.

ROUTINE USES:

Your records may be disclosed outside of DoD to investigate waste, fraud, abuse, security and privacy concerns. Use and disclosure of your records may also occur in accordance with the DoD Blanket Route Uses published at http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses.aspx and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

SYSTEM OF RECORDS NOTICE:

The applicable system of records notices are EDTMA 04, Medical/Dental Care and Claim history Files (October 27, 2015, 80 FR 65720) published at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/ and A0040-5a DASG DoD, Defense Medical Surveillance System (August 19, 2009, 74 FR 41877) published at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569970/a0040-5a-dasg-dod.aspx.

DISCLOSURE:

Voluntary. However, failure to provide all the requested information may result in you not meeting dental readiness requirements and may affect timely payment of dental provider claims.

I Agree