PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting personally identifiable information through the DD Form 2813, Department of Defense Active Duty/Reserve/Guard/Civilian Forces Dental Examination
AUTHORITY: 10 U.S.C. 136, 10 U.S.C. 1074f; DoD Directives 1404.10, 5101.1, 5136.01, and 6490.02E; DoD Instruction 6025.19; and E.O. 9397 (SSN), as amended.
PURPOSE: To obtain information in order to record an assessment of an individual’s dental health.
ROUTINE USES: Information collected may be used and disclosed generally as
permitted under 45 CFR Parts 160 and 164, Health Insurance
Portability and Accountability Act (HIPAA) Privacy and Security
Rules, as implemented by DoD 6025.18-R, the DoD Health
Information Privacy Regulation. In addition to those disclosures
generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of
1974, the DoD “Blanket Routine Uses” under 5 U.S.C. 552a(b)(3)
apply to this collection. Information from this system may be
shared with other Federal and State agencies and civilian health
care providers, as necessary, to provide medical care and treatment
and to guide possible referrals.
DISCLOSURE: Voluntary; however, failure to provide the information may result in delays for assessing your dental health needs for military service and/or for possible deployment outside the United States and its territories and possessions.
TMA PCLO Final_4-13-12
| File Type | application/msword |
| File Title | MedManager PIA Questions |
| Author | A Preferred User |
| Last Modified By | tevans2 |
| File Modified | 2012-04-13 |
| File Created | 2012-04-13 |