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Patient Resources

Forms

Belvoir Hospital Forms

  • Active Duty Dental Claim Form
    United Concordia's network dentists will file a claim on your behalf. If you are approved to utilize a non-network dentist, you may be required to submit your own claim form. United Concordia's network dentists will file a claim on your behalf.
  • DD Form 2792
    "Family Member Medical Summary", JAN 2021 This form is used to document a family member's special medical needs and for enrollment in the Exceptional Family Member Program. This information assists military assignment personnel in matching the family member's special medical needs against the availability of medical services at the projected duty station.
  • DD Form 2792-1
    "Special Education/Early Intervention Summary," JAN 2021 This form is used to document the special education needs of a child with a disability, birth through age 21, and for enrollment in the Exceptional Family Member Program. This information will assist military assignment personnel in matching the child's special education needs against the availability of educational services at the projected duty station.
  • DD Form 2870
    "Authorization for Disclosure of Medical or Dental Information," DEC 2003
  • DD Form 877
    "Request for Medical/Dental Records or Information," SEP 67

Defense Health Agency Forms

TRICARE Forms

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