ATTACHMENT 02 PWS.pdf

Attachment 2 | 4 September 2025

PERFORMANCE WORK STATEMENT (PWS)

FOR

Extensive Dental Treatment Services

1.0 General:

1.1 Scope: The contractor shall provide extensive non-personal dental treatment services as needed for Soldiers in the Arizona Army National Guard (AZARNG), as defined in this PWS.

1.2 Background: AZARNG has a requirement to ensure medical readiness for Service Members by providing services directly promoting comprehensive medical readiness, ensuring global deployability. Dental readiness directly impacts deployability of soldiers.

Soldiers coded as Dental Readiness Code (DRC) 3 are non-deployable due to having oral conditions that will most likely result in a dental emergency within 12 months if not treated.

Utilizing a contracted dental office for extensive treatment services would greatly improve the AZARNG’s ability to deploy soldiers and prevent oral conditions from worsening.

1.3 Period of Performance (PoP): The period of performance shall be one base year of 12 months or once the AZARNG has utilized all funds provided to the contractor for extensive dental treatment services.

1.4 General Information:

1.4.1 Place and Performance of Services: The contractor shall provide services from their own dental office. The contractor shall be able to provide services during their dental office’s normal business hours. The contractor may be asked to provide services outside their normal business hours but can decline the request if they choose.

1.4.2 Quality Control (QC): The Contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s QCP is the means by which it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS). After acceptance of the QCP, the contractor shall obtain the Contracting Officer’s (KO’s) acceptance in writing of any proposed changes to its QCP. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS).

1.4.3 Quality Assurance (QA): The Government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government will do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and acceptable quality level(s) or defect rate(s).

2.0 Definitions and Acronyms:

2.1 Definitions:

2.1.1 Contractor. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

2.1.2 Contracting Officer (KO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.1.3 Contracting Officer’s Representative (COR). An employee of the U.S. Government designated by the KO to monitor contractor performance. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as the direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.4 Defective Service. A service output which does not meet the standard of performance associated with the Performance Work Statement.

2.1.5 Deliverable. A deliverable is anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.1.6 Key Personnel. N/A

2.1.7 Dental Readiness Code (DRC). The DRC is used to determine if a soldier has dental issues that will prevent them from being medically ready/deployable.

2.1.8 Physical Security. N/A

2.1.9 Quality Assurance. The government procedures to verify services being performed by the Contractor are performed according to acceptable standards.

2.1.10 Quality Assurance Surveillance Plan (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.11 Quality Control. All necessary measures taken by the Contractor to assure the quality of an end product or service meets contract requirements.

2.1.12 Subcontractor. One that enters into a contract with a prime contractor. The Government does not have privy of contract with the subcontractor.

2.2 Acronyms:

AFARS Army Federal Acquisition Regulation Supplement AMEDD Army Medical Department AR Army Regulation ARNG Army National Guard AUP Acceptable Use Policy AT/OPSEC Antiterrorism/Operational Security BBP Best Business Practices BI Background Investigation CFR Code of Federal Regulations CM Contract Manager COMSEC Communications Security CONUS Continental United States (excludes Alaska and Hawaii) COR Contracting Officer Representative COTS Commercial-Off-the-Shelf CMRA Contractor Manpower Reporting Application DA Department of the Army DD250 Department of Defense Form 250 (Receiving Report) DD254 Department of Defense Contract Security Requirement List DENCLASS Dental Classification Module D&F Determination and Findings DFARS Defense Federal Acquisition Regulation Supplement DHA Defense Health Agency DOD Department of Defense DODD Department of Defense Directive DODAAC Department of Defense Activity Address Code DODM Department of Defense Manual DSS Deputy State Surgeon eCASE Electronic Case Management FAR Federal Acquisition Regulation FBI Federal Bureau of Investigation FOUO For Official Use Only FPCON Force Protection Condition FSO Corporate Facility Security Officer FY Fiscal Year GFP/M/E/S Government Furnished Property/Material/Equipment/Services HIPAA Health Insurance Portability and Accountability Act of 1996 HQDA Headquarters Department of Army HRR Health Readiness Record HSS Health Services Specialist IA Information Assurance IAW In Accordance With IMR Individual Medical Readiness INARNG Indiana Army National Guard INCAP Incapacitation IS Information System(s) IT Information Technology

JTR Joint Travel Regulation KO Contracting Officer LAN Local Access Network LPN Licensed Practical Nurse LPVN Licensed Practical Vocational Nurse LOD Line of Duty MAR2 MOS Administrative Review Board MEB Military Evaluation Board MEDCHART Medical Electronic Data Care History and Readiness Tracking MEDCOM Medical Command MEDPROS Medical Protections System MHA Medical Health Assessment MHS Genesis Military Health Systems Genesis MMSO Military Medical Support Office MODS Medical Operational Data Systems MMPS Medical Management Processing System MND Medically Non-deployable MRC3 Medical Readiness Class 3 Non-Deployable MRDP Medical Readiness Decision Point MRE Medical Readiness Event MRP2 Medical Retention Processing MOS Military Occupational Specialty MTF Military Treatment Facility MTU Medical Transition Unit NACI National Agency Check with Inquiries NCO Non-Commissioned Officer NDR Non-Duty Related NDR-PEB Non-Duty Related Physical Evaluation Board NARSUM Narrative Summary NGB National Guard Bureau NTV Non-Tactical Vehicle OCI Organizational Conflict of Interest ODC Other Direct Costs OPM Office of Personnel Management OPSEC Operations Security OTSG Office of the Surgeon General OY Option Year PEB Physical Evaluation Board PEBLOS Physical Evaluation Board Liaison Officers PEC Physical Exam Center PCM Primary Care Manager PHA Periodic Health Assessment PII Personally Identifiable Information PIPO Phase In/Phase Out PIV Personal Identity Verification POC Point of Contact

PROFIS Professional Filler System PRS Performance Requirements Summary PSIP Personnel Security Investigation Portal PWS Performance Work Statement QA Quality Assurance QAP Quality Assurance Program QASP Quality Assurance Surveillance Plan QC Quality Control QCP Quality Control Program RAPIDS Real-Time Automated Personnel ID System RN Registered Nurse ROI Release of Information SM Service Member SOP Standard Operating Procedures SRP Soldier Readiness Processing SSN Social Security Number STR Soldier Treatment Records TA Trusted Agent TARP Threat Awareness Reporting Program TASS Trusted Associate Sponsorship System TEM Traumatic Event Management TE Technical Exhibit UIC Unit Identification Code USDI Under Secretary of Defense Intelligence

3.0 Government Furnished Property, Material, Equipment and Services (GFP/M/E/S): The Government will provide the property, material, equipment, and/or services listed below solely for the purpose of performance under this contract: N/A

3.1 Property: N/A

3.2 Materials: N/A.

3.3 Equipment: N/A

3.4 Utilities: N/A

4.0 Contractor Furnished Property, Materials, and Equipment (CFP/M/E):

4.1 General: Except for those items specifically stated to be Government-Furnished in Paragraph 3.0, the contractor shall furnish everything required to perform these services as required by the contract.

4.2 Secret Facility Clearance: N/A.

5.0 Requirements:

5.1 The contracted dental office, at a minimum, must be able to provide the following dental treatments: Root Canal Therapy, Crowns, surgical extractions of teeth with exposed roots/impacted teeth/erupted teeth, Resin Based Composites, Amalgam, and Core Build-Up.

5.1.2 The contracted dental office must be able to see a soldier for a dental exam or treatment within 14 calendar days of the dental treatment request being submitted to the dental office.

5.1.3 The Standard Form (SF) 603 will be submitted to the contracted dental office by the AZARNG’s OTSS representative to request dental treatment for a Soldier. The SF 603 will be sent via DODSafe.

5.1.3.1 The SF 603 is filled out by AZARNG dentists and lists the DRC3 dental treatment that is required convert a soldier to DRC2. The SF 603 will be used by the dental office to provide an estimate of the cost of treatment for each soldier.

5.1.3.2 The Arizona Army National Guard will not pay for any dental treatment that is not listed on the SF 603 provided. If additional treatment is required, a dentist from the Arizona Army National Guard must revise the treatment plan provided by the dental office and approve it before treatment can be performed.

5.1.3.3 The contracted dental office must provide an updated treatment plan and any imaging taken when requesting to do additional treatment on a soldier.

5.1.3.4 The contracted dental office must submit an invoice on the last business day of each month that shows the cost of all treatments that were provided that month. They must also provide invoices as requested by the Arizona Army National Guard.

5.1.3.5 The contracted dental office must utilize Soldier’s insurance prior to using the funds provided by the Arizona Army National Guard.

5.1.3.6 The contracted dental office must provide a signed DD Form 2813 to the Arizona Army National Guard via DODSafe or by an approved AZARNG submission site once any treatment has been performed on a Soldier and include the Soldiers DRC code.

5.1.4 Contract Manager (CM): The contractor shall designate a CM who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the CM is absent, shall be designated in writing to the KO. The CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the Contracting Officer’s Representative (COR) to resolve issues, receive technical instructions, and ensure adequate performance of services.

5.1.5 Combating Trafficking in Persons: The United States Government has adopted a zero-tolerance policy regarding trafficking in persons. Contractors and contractor employees shall not engage in severe forms of trafficking in persons during the period of performance of the contract; procure commercial sex acts during the period of performance of the contract; or use forced labor in the performance of the contract. The Contractor shall notify its employees of the United States Government’s zero tolerance policy, the actions that will be taken against employees for violations of this policy. The contractor shall take appropriate action, up to and including termination, against employees or subcontractors that violate the US Government policy as described at FAR 22.17.

5.1.6 Data Rights: N/A

5.1.7 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract will not disclose information regarding number of service members they are treating.

5.1.8 Dental services shall be performed by licensed professionals. The Contractor shall be held liable and are responsible for ensuring and verifying the appropriate level of Credentialing Privileging for all contract providers in support of the AZARNG. Providers must not have existing open board complaints. Previous disciplinary action against a dentist by the Arizona or other States Board of Dentistry may preclude them from being a provider under this contract, unless approved by the State Dental Officer or Deputy State Surgeon.

5.1.9 Phase In/Phase Out Periods. Reserved.

5.9 Contractor Manpower Reporting Application (CMRA): N/A

5.9.1 The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the National Guard Bureau via a secure data collection site.

5.9.2 The contractor shall completely fill in all required data fields using the following web address: http://www.sam.gov/. Reporting inputs shall be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year. Contractors may direct questions to the help desk at http://www.sam.gov/.

The Unit Identification Code (UIC) for the Requiring Activity: W903GU.

Issuing Office DoDAAC: W912L2.

6.0 Applicable Publications: Publications applicable to this PWS are listed within.

Publication (Chapter/Page)

Date of Publication

Mandatory or Advisory

Website

Fed Acquisition Regulation Mandatory https://www.acquisition.gov/ ?q=browsefar http://www.ecmra.mil/ http://www.sam.gov/ http://www.acquisition.gov/

Defense Fed Acquisition Regulation Supplement

Mandatory http://www.acq.osd.mil/dpap/ dars/dfarspgi/current/index.h tml DoDI 5400.11

Department of Defense Privacy and Civil Liberties Programs

01/29/2019 Mandatory https://www.esd.whs.mil/Dire ctives/issuances/dodi/

DoD 5400.11-R Dept of Defense Privacy Program

05/14/2007 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

DoDM 1000.13-M-V1 DoD Identification (ID) Cards

01/23/2014 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

(Encl 2, para 3.b) Federal Information Processing Standards (FIPS) Publication 201-2 Personal Identity

Verification (PIV) of Federal Employees and Contractors (paragraph 9)

August

Mandatory http://nvlpubs.nist.gov/nistpu bs/FIPS/NIST.FIPS.201-

2.pdf

HSPC (Homeland Security Presidential Directive) -12 Policy for a Common

Identification Standard for Fed Employees and Contractors

08/27/2004 Mandatory https://www.dhs.gov/homela nd-security-presidential-directive-12

DoDM 5200.2 Procedures for the DoD Personnel Security Program

(PSP)

01/01/1987 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

DoDD 8140.01 Cyberspace Workforce Management

08/11/2015 Mandatory http://www.dtic.mil/whs/direc tives/corres/dir.html

DoD 8570.01-M Information Assurance Workforce

Improvement Program

12/19/2005 (Change 4:

11/10/2015)

Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

AR 25-2

Information Assurance

10/24/2007 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 530-1

Operations Security 09/26/2014 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 381-12

Threat Awareness and Reporting Program

(TARP) (Section II, Para 2-4.b)

06/01/2016 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 40-501

Standards of Medical Fitness 12/14/2016 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR

AR 40-66

Medical Record Administration and Health

Care Documentation

06/17/2008 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR.

AR 40-68

Clinical Quality Management 02/26/2004 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR.

AR 635-40

Physical Evaluation for Retention, Retirement, or Separation

02/08/2006 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR AR 58-1 Management, Acquisition , and Use of Motor Vehicles

04/03/2019 Mandatory https://armypubs.army.mil/Pr oductMaps/PubForm/Details .aspx?PUB_ID=1005116

6.1 Applicable Forms: Forms applicable to the PWS are listed below:

http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.esd.whs.mil/Dire http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/direc http://nvlpubs.nist.gov/nistpu http://www.dhs.gov/homela http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/dir.html http://www.dtic.mil/whs/directives/corres/dir.html http://www.dtic.mil/whs/direc http://armypubs.army.mil/Se http://armypubs.army.mil/Se http://armypubs.army.mil/Se http://www.apd.army.mil/Sea http://www.apd.army.mil/Sea http://www.apd.army.mil/Sea http://armypubs.army.mil/Se

Form Date Website

DD 1172-2

Application for Identification

Card/DEERS Enrollment

Jan 2014 http://www.dtic.mil/whs/directives/forms/index.htm

I-9 Employment Eligibility

Verification

11/21/91 http://www.ilw.com/forms/i-9fillable.pdf

DD 441

Department of Defense

Security Agreement

May http://www.dtic.mil/whs/directives/forms/dd/ddforms0001- 0499.htm

DD 250

Material Inspection and

Receiving Report

Aug http://dtic.mil/whs/directives/forms/dd/ddforms0001- 0499.htm

DD 2766

Adult Preventive and Chronic

Care Flowsheet

Mar http://www.dtic.mil/whs/directives/forms/dd/ddforms2500- 2999.htm

DA Form 3822 Report of Mental Status Evaluation

Mar http://www.apd.army.mil/pub/eforms/DR_a/pdf/DA%20F ORM%203822.pdf

SF 600

Chronological Record of

Medical Care

May http://www.gsa.gov/portal/forms/type/SF#1-1000

DD254

Department of Defense

Contract Security Classification Specifica

APR

https://www.esd.whs.mil/Portals/54/Documents/DD/forms /dd/dd0254.pdf

DD2813

Active Duty/Reserve Forces Dental Examination

Mar 2017 http://www.esd.whs.mil/Directives/forms/dd2500_2999/ http://www.dtic.mil/whs/directives/forms/forminfo/forminfopage2479.html http://www.dtic.mil/whs/directives/forms/forminfo/forminfopage2479.html http://www.dtic.mil/whs/directives/forms/index.htm http://www.ilw.com/forms/i-9fillable.pdf http://www.dtic.mil/whs/directives/forms/dd/ddforms0001-http://dtic.mil/whs/directives/forms/dd/ddforms0001-http://www.dtic.mil/whs/directives/forms/dd/ddforms2500-http://www.apd.army.mil/pub/eforms/DR_a/pdf/DA%20F http://www.gsa.gov/portal/forms/type/SF#1-1000 http://www.esd.whs.mil/Portals/54/Documents/DD/forms http://www.esd.whs.mil/Directives/forms/dd2500_2999/

TECHNICAL EXHIBIT 1: PERFORMANCE REQUIREMENTS SUMMARY

PWS

Paragraph

Task Performance Standard Acceptable Quality Levels

(AQL)

Surveillance Method / By

Whom

5.1.2 Schedule Soldier’s

for treatment within 14 calendar days of a request being received

Ensure Soldier’s receive an appointment within 14 calendar days of the dental office receiving the request

100% of Soldier’s scheduled within timeline

COR

5.1.3.4 Submit a tracker

showing treatment provided and costs of treatment provided

Submit the tracker no later than the last business day of the month every month.

100% of reports completed within timeline COR

5.1.3.6 Submit a DD Form

2813 for each soldier that receives any dental treatment

Submit the DD Form 2813 immediately following any treatment provided

100% of forms submitted

COR

TECHNICAL EXHIBIT 2: Estimated Workload Data The chart below represents the estimated procedures to be completed in a 12 month period of performance. (approximately 160 patients).

Quantity ADA Code

Procedure Description

3 D0140 LIMITED ORAL EVALUATION

1 D0220 Intraoral- Periapical First Film 1 D0230 30; Intraoral- Periapical Each Additional Film 1 D1110 Prophylaxis-Adult 21 D2140 AMALGAM-One Surface 39 D2150 Amalgam-Two Surfaces 15 D2160 Amalgam-Three Surfaces 2 D2161 Amalgam-Four or more Surfaces 13 D2330 Resin Based Composite-One Surface 8 D2331 Resin Based Composit-Two Surfaces 5 D2332 Resin Based Composite-Three Surfaces 9 D2335 Resin Based Composite-Four or more Surfaces 6 D2391 Resin Based Composite-One Surface 20 D2392 Resin Based Composite-Two Surfaces 11 D2393 Resin-3 surfaces, posterior 6 D2394 Resin Based Composite-Four or more Surfaces 2 D2740 Crown-porcelin/cermanic 2 D2750 Crown-Porcelin Fused to High Noble Metal;

Surfaces 6 D2931 Prefabricated Stainless Steel Crown- Permanent

Tooth 38 D2950 Core buildup [including any pins] 1 D2952 Cast Post and Core in Addition to Crown 4 D3120 Pulp Cap-Indirect [Excluding Final Restoration] 2 D3310 Anterior Root Canal Therapy 4 D3320 Bicuspid Root Canal Therapy 13 D3330 Molar Root Canal Therapy 1 D3347 Bicuspid Root Canal Retreatment 5 D3348 Molar Root Canal Retreatment 1 D4212 Gingivectomy or gingivoplasty to allow for restorative procedure per tooth 5 D4355 Full Mouth Debridement 15 D7140 Extraction[Erupted Tooth or Exposed Root]

41 D7210 SURGICAL REMOVAL OF ERUPTED TOOTH

23 D7230 Removal of Impacted Tooth-Partial Bony 6 D7240 Removal of Impacted Tooth-Completely Bony;

Symptomatic

1 D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH

ROOTS

HEALTH RECORD

SECTION I, DENTAL EXAMINATION

REMARKS

A. CALCULUS

6. SEX

PLACE OF EXAMINATIONDATE

4. MISSING TEETH AND EXISTING RESTORATION

GENERAL SERVICES ADMINISTRATION SF Form 603 (Rev. 10/75)

DENTAL

PARTIAL

1 2 3 4

FULL

7. RACE 8. GRADE, RATING, OR POSITION

LU

DATE

SEPARATION

SECTION II. PATIENT DATA

FULL MOUTH

PERIAPICAL

E. INDICATE X-RAYS USED IN THIS EXAMINATION

PLACE OF EXAMINATION

1. PURPOSE OF EXAMINATION

9. ORGANIZATION UNIT

SIGNATURE OF DENTIST COMPLETING THIS SECTION

ABNORMALITIES OF OCCLUSION - REMARKS

INITIAL OTHER (Specify)

2. TYPE OF EXAM 3. DENTAL CLASSIFICATION

1 2 3 4 5

SIGNATURE OF DENTIST COMPLETING THIS SECTION

5. DISEASES, ABNORMALITIES, AND X-RAYS

MODERATE HEAVYSLIGHT

B. PERIODONTOCLASIA

GENERALLOCAL

INCIPIENT MODERATE SEVERE

C. STOMATITIS (Specify)

VINCENT'SGINGIVITIS

D. DENTURES NEEDED

(Include dentures needed after indicated extractions)

LU

POSTERIOR

BITE-WINGS

OTHER (Specify)

10. COMPONENT OR BRANCH 11. SERVICE DEPT., OR AGENCY

12. PATIENT'S LAST NAME - FIRST NAME - MIDDLE NAME 13. DATE OF BIRTH (DAY-MONTH-YEAR) 14. IDENTIFICATION NUMBER

Technical Exhibit 3: SF Form 603 and DD Form 2813

SF Form 603 (Rev. 10/75) Back

SECTION III. ATTENDANCE RECORD

15. RESTORATIONS AND TREATMENTS (Completed during service) 16. SUBSEQUENT DISEASES AND ABNORMALITIES

REMARKS REMARKS

17. SERVICES RENDERED

DATE DIAGNOSIS-TREATMENT CLASS OPERATOR AND DENTAL FACILITY INITIALS

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2813, NOV 2021

CUI when filled

CUI when filled

Controlled by: DHA CUI Category: PRVCY

LDC: FEDCON

POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil

DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN

FORCES DENTAL EXAMINATION

OMB No. 0720-0022 OMB approval expires 20260331

The public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT

AUTHORITIES: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Chapter Ch. 55, Medical and Dental Care; 10 U.S.C. 1097a, TRICARE Prime: Automatic Enrollments; Payment Options; 10 U.S.C. 1097b, TRICARE Prime and TRICARE Program: Financial Management; 10 U.S.C. 1079, Contracts for Medical Care for Spouses and Children: Plans; 10 U.S.C. 1079a, TRICARE Program: Treatment of Refunds and Other Amounts Collected Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); 10 U.S.C. 1086, Contracts for Health Benefits for Certain Members, Former Members, and Their Dependents; 10 U.S.C. 1095, Health Care Services Incurred on behalf of Covered Beneficiaries: Collection From Third-party Payers; 42 U.S.C. 290dd-2, Confidentiality Of Records; 42 U.S.C 42 U.S.C. Ch. 117, Sections 11131-11152, Reporting of Information; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD 6025.18-R, DoD Health Information Privacy Regulation; and E.O. 9397 (SSN).

PURPOSE: To collect patient information necessary to determine the patient’s readiness to participate in a military deployment.

ROUTINE USES: Information in your records may be disclosed to other components within the Department of Defense to determine your readiness to participate in a military deployment. Information in your records may also be disclosed to private physicians and Federal agencies, including the Departments of Veterans Affairs, Health and Human Services, and Homeland Security in connection with your medical care; other federal, state, and local government agencies to determine your eligibility for benefits and entitlements and for compliance with laws governing public health matters; and government and non-government third parties to recover the cost of healthcare provided to you by the Military Health System. Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, “Military Health Information System,” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/ DHA/EDHA-07.pdf

DISCLOSURE: Voluntary. However, failure to provide the information requested may result in delays in assessing your dental health needs for military service and/or for possible deployment.

1. SERVICE MEMBER'S NAME (Last, First, Middle Initial) 2. DoD ID Number 3. BRANCH OF SERVICE

4. UNIT OF ASSIGNMENT 5. UNIT ADDRESS

6. EXAMINATION RESULTS

Dear Doctor, The individual you are examining is an Active Duty/Guard/Reserve/Civilian member of the United States Armed Forces. This member needs your assessment of his/her dental health for worldwide duty. Please mark (X) the block that best describes the condition of the member, using as a suggested minimum a clinical examination with mirror and probe, and bitewing radiographs. This form determines fitness for prolonged duty without ready access to dental care and is not intended to document comprehensive dental needs.

(1) Patient has good oral health and is not expected to require dental treatment or reevaluation for 12 months

(2) Patient has some oral conditions, but you do not expect these conditions to result in dental emergencies within 12 months if not treated (i.e., requires prophylaxis, asymptomatic caries with minimal extension into dentin, edentulous areas not requiring immediate prosthetic treatment).

(3) Patient has oral conditions that you do expect to result in dental emergencies within 12 months if not treated.

Examples of such conditions are: (X the applicable block or specify in the space provided)

(a) Infections: Acute oral infections, pulpal or periapical pathology, chronic oral infections, or other pathologiclesions and lesions requiring biopsy or awaiting biopsy report.

(b) Caries/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective restorations or temporary restorations that patients cannot maintain for 12 months.

(c) Missing Teeth: Edentulous areas requiring immediate prosthodontic treatment for adequate mastication, communication, or acceptable esthetics.

(d) Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis, periodontal abscess, progressive mucogingival condition, moderate to heavy subgingival calculus, or periodontal manifestations of systemic disease or hormonal disturbances.

(e) Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.

(f) Other: Temporomandibular disorders or myofascial pain dysfunction requiring active treatment.

(4) If you selected Block (3) above, please indicate the condition(s) you identified in this patient if they appear above, or briefly describe the condition(s) below:

(5) Were X-rays consulted? IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)

7. DENTIST'S NAME (Last, First, Middle Initial) 8. DENTIST'S TELEPHONE NUMBER (Include Area Code)

9. DENTIST'S SIGNATURE 9. DENTIST'S LICENSE NUMBER 10. DATE OF EXAMINATION (YYYYMMDD)