Privacy Act Statement - Electronic

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. Information may also be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD “Blanket Routine Uses” published at:

http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html.

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

Electronic Format