J-5b Sample Command Memo v1.docx

Attachment J-5b Sample Command Memorandum for Authorization Request

[COMMAND LETTERHEAD]

From: [Command name and mailing address for reply mail]

To: Dental Service Officer in Charge, XXXXX, Attn: Dental Pre- Authorizations, PO Box xxxxx, City, State Full Zip Code

Subj: REQUEST FOR AUTHORIZATION OF CIVILIAN DENTAL CARE

FOR [NAME, RANK, SERVICE, AND SSN OF SERVICE MEMBER].

Encl: (1) Copy of civilian dental treatment plan

(2) Dental x-rays and/or photographs

(3) Copy of dental record (SF 603’s) [Only if the records are current (less than one year) or applicable to the request. Do not send old records.]

1. Authorization is requested for civilian dental care indicated by enclosures (1- 3). We understand that any authorization is for this request only, and may not apply if the information provided changes.

2. This service member is on Active Duty (or other Defense Enrollment Eligibility Reporting System (DEERS) eligible status).

The following information is provided:

a. Total estimated cost of this treatment:

b. Date of last military dental exam:

c. Service member’s duty location and work phone number:

d. Date assigned to a Geographically Separated Unit (GSU):

e. Projected Rotation Date:

f. Expiration of obligated service:

g. The nearest Federal / Military Dental Treatment Facility (DTF): [Name and distance – Include VA medical center with dental sharing agreement, if known]

3. My point of contact is: [Name, Rank, Telephone number of Command’s Medical Representative, Health Benefits Advisor (HBA), or Other knowledgeable person]

[Signed by Commander or Designated Representative]