If you choose not to use the online enrollment tool, use this enrollment form to enroll or to cancel enrollment. Please review the instructions on page 2 for filling out the enrollment form.

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TDP Claims Form (CONUS)

Use this form to file a claim for services rendered in the Continental United States (CONUS). For your convenience, this form can be filled out online, printed and mailed to United Concordia.

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TDP Claims Form (OCONUS)

Use this form to file a claim for services rendered Outside of the Continental United States (OCONUS).

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NARF (Non Availability Referral - OCONUS Only)

A NARF is an OCONUS form used by Overseas Dental Treatment Facilities (ODTFs) and TRICARE Area Offices (TAOs) to refer enrolled members to local host country dentists for orthodontic services. For your convenience, this form can be filled out online, printed and mailed to United Concordia.

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Custodial Parent Release Form

This form should only be completed when a natural parent who is listed on a TDP contract is authorizing the other natural parent who is not listed on the TDP contract to receive information on their natural child under the age of 18.

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POA (Power of Attorney)

Use this form to submit Power of Attorney information in order to manage the TDP account on behalf of the sponsor.

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HIPAA Privacy Release Form

This form should be completed to release PHI between spouses, for children 18 years and older or any other person not authorized to receive information without written authorization. This is necessary due to HIPAA Privacy Regulations.

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Appointment of Individual to Act As Appeal Representative Form

This form will need to be completed by the patient/or parent of a child under the age of 18 when a non-network provider is requesting a reconsideration on their patient's behalf.

This form will also need to be completed if a member would like to appoint an individual to appeal a claim on their behalf. The member must complete the Request and Authorization for Disclosure of Health Information form and the Appointment of Individual to Act as Appeal Representative Form. Both forms must be received and completed entirely before an appeal can be processed.

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Appeals

You may appeal a claim denial by completing the Appeal Form. The form must be completed entirely and submitted to United Concordia before an appeal can be processed. In order to submit a formal review request, the provider must have the attached Appointment of Individual to As Appeal Representative form signed by the beneficiary. The signed appointment appeal form MUST be included in the formal review.

Online Form

Grievance

If you would like to submit a concern regarding a quality of care issue, complete the attached form and return it to United Concordia's Grievance Unit. You can complete it online or print the form and mail/fax it to United Concordia.

Online Form

Fraud Complaint Form

If you believe a dentist or entity has received insurance money through the submission of a false claim, you should report this information to the Special Investigations Unit (SIU).

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DD Form 2813 (Guard Reserve - Dental Readiness Classification)

The DD Form 2813, DoD Active Duty/Reserve Forces Dental Examination, will be used to assist the TDP-enrolled National Guard/Reserve forces in documenting member dental health.

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Nominate My Dentist

If you would like to nominate your dentist for participation with United Concordia, please submit the Nominate My Dentist form.

Online Form

Use this form to submit a question to a United Concordia representative regarding the TDP or your benefits.

Online Form