** Important information for TDP enrollees**

COVID-19 update: To ensure the safety of both patients and dental staff, the American Dental Association is asking that all elective (non-emergency) dental procedures be postponed at this time. Click here for more information on dental emergencies.

If you are experiencing a dental emergency (emergency dental care includes any treatment necessary to relieve pain, treat infection, or control bleeding) you should:

  • Contact your dentist
  • Call United Concordia’s dental emergency line at 1-800-858-0051*

* Note that this line is to be used for dental emergencies only.  It is available Sunday, 6:00 pm - Friday, 10:00 pm, Eastern Time.

You may also seek care for a dental emergency from your closest emergency room; however, please understand that the healthcare system may be overwhelmed with medical patients at this time and it is recommended that you contact your dentist and/or United Concordia for assistance.

** Important information for dentists.** Learn more.

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Contact Us - Health Records Release

Authorize Health Records Release

Confirm your information

The request for release of information is being made for the TDP member identified below.

Privacy Act Statement

This statement serves to inform you of the purpose for collecting personal information required by the TRICARE Dental Program (TDP) and how it will be used.

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR 199.13, TRICARE Dental Program; and E.O. 9397 (SSN), as amended.

PURPOSE: To collect information from you to manage your enrollment in the TDP, administer your benefits, and pay for the services you receive.

ROUTINE USES: Your records may be disclosed to providers of care and other business entities on matters relating to eligibility, claims pricing and payment, fraud, quality assurance, program integrity, and the coordination of benefits. Your records may also be disclosed outside of the Department of Defense (DoD) in accordance with the DoD Blanket Routine Uses published at Caution-http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/ and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the Health Insurance Portability and Accountability Act Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

DISCLOSURE: Voluntary. If you choose not to provide this information, no penalty may be imposed, but absence of the requested information may delay or prevent your receipt of TDP services.

Decline Decline Decline
Sponsor's SSN or DBN
Address Information
Dependent Child's Full Name
Information that may be used or disclosed


The information will be used for
Persons/organizations authorized to receive the information

I understand that I may revoke this authorization at any time by sending a written notice of my revocation to:

United Concordia Companies, Inc.
TDP Customer Service
PO Box 69450
Harrisburg, PA 17106

I understand that revocation of this authorization will not affect any action UCCI or its subsidiaries, affiliates, business associates, etc. took in reliance on this authorization before it received my written notice of revocation. I also understand that without my written authorization, UCCI may not use or disclose my health information for any reason except those described in UCCI’s Notice of Privacy Policies and Practices. Unless otherwise revoked, this authorization will expire on the above date, event or circumstance.

I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this authorization.

I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described above are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws.

I release UCCI, its affiliated companies, employees, officers and business associates from legal liability for any recipient’s use or disclosure of information released by UCCI in reliance on this authorization.


Signature Date: 03/30/2020
Beneficiary's Signature

* I acknowledge and agree that by selecting this box I am electronically signing this document and intend for it to be my legal signature. I represent that I am authorized to sign this document and that all information provided is correct to the best of my knowledge.

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Access Additional TDP Forms

  • Custodial Parent Release
  • POA
  • HIPAA Privacy Release
  • Appointment of Appeal Representative
  • File Appeal
  • Grievance
  • Fraud Complaint
  • Contact Us
  • Custodial Parent Release
  • POA
  • HIPAA Privacy Release
  • Appointment of Appeal Representative
  • File Appeal
  • Grievance
  • Fraud Complaint
  • Contact Us
  • Custodial Parent Release
  • POA
  • HIPAA Privacy Release
  • Appointment of Appeal Representative
  • File Appeal
  • Grievance
  • Fraud Complaint
  • Contact Us

How to allow non-custodial parents to receive information

By completing the information on this form, you are authorizing United Concordia Companies, Inc. to release individual health information protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), or by state law protecting the privacy of health information. This form should be used to allow spouses, non-custodial parents, etc. to receive information for the individuals indicated on this form. Authorization will remain in effect indefinitely, unless the authorization is revoked in writing.

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