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.
Expiration Date or Condition Voiding Authorization
Full Name of Individual Authorized to Release Information
Relationship to TDP Enrollee Select One Self Custodial Parent Legal Guardian
Phone
Email Address
Address 1
Address 2
(optional)
City
I understand that I may revoke this authorization at any time by sending a written notice of my revocation to:
United Concordia Companies, Inc.
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.
Authorized signature of member or personal representative *
Signature Date: 10/19/2021
