Pencil Entries

Enter the patient's command and grade or rate for active duty. For all others enter their preferred form of address.

Table 1-1.\Family Member Prefix Codes

Record Category

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.

Annual Verification

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.

DATA ON INSIDE FRONT COVER OF THE DENTAL RECORD JACKET

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should be entered at the time of record check-in (receipt) and should be kept current at all times by erasing previous, outdated entries.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."

Record Retirement Tape

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.

Figure 2-8.\DD 2005, Privacy Act Statement.

Figure 2-9.\Disclosure Accounting Record.

right margin of the inside back cover of the dental record jacket. Use 1/2-inch wide tape in strips l-inch long. Attach the tape in the space provided and extend the tape around the edge of the jacket to the back. Mark jackets with the following color sequence, which is repeated at 6-year intervals:

A record will be retired January 1 on the calendar year (CY) following a 24-month period of no patient examination or treatment. For example, a patient last seen during CY 1995 will have jackets taped green to show the tentative record retirement date of 1 January 1998. The retirement year tape color sequence will be updated as records are pulled from the file for care and treatment. When patients are treated during CY 1996, the record retirement date should be changed by attaching red tape over the green indicating a new tentative retirement date of 1 January 1999.