DATA ON INSIDE FRONT COVER OF THE
DENTAL RECORD JACKET
Below the pencil entries box, indicate the record
category by enteringan X in the box marked Dental
Service and Status
Immediately below the record category box,
indicate the sponsors branch of military service by
entering an X in the appropriate box. If the sponsor
is not an active duty Navy or Marine Corps member,
enter an X in the Other box and write the service
and rank/rate on the line provided. Check remaining
boxes in this section as applicable with additional
comments as follows:
Retired. Check box if applicable and indicate
service and rank/rate on line provided.
Family Member. Check box if applicable and
indicate relationship to sponsor.
Family Member Insurance. Check Yes or
No regarding dental insurance the family
member may have. (e.g. United Concordia
Companies, Inc. (UCCI), DELTA, HUMANA,
Blood Type. Indicate blood type of patient.
The format printed on the inside of the jacket front
cover (fig. 2-7) should be completed in pencil only.
This information should be entered at the time of
record check-in (receipt) and should be kept current at
all times by erasing previous, outdated entries. Have
member complete blocks that are applicable. Most
blocks are self-explanatory.
Imprint of DD 2005, Privacy Act Statement
The Imprint of DD 2005, Privacy Act Statement
form (fig. 2-8) is preprinted and located in front of the
center page in the dental record jacket. It must be
signed in black ink by the patient, the parent, or the
guardian must sign if the patient is a minor.
Disclosure Accounting Record
The Disclosure Accounting Record (fig. 2-9) is
preprinted and located on the back of the center page of
the dental record jacket. It is self-explanatory and will
be filled out as needed.
The Forensic Examination form is preprinted and
located on the inside back cover of the dental record
jacket. The instructions for completing the Forensic
Examination Form are discussed in Dental
Technician, Volume 2, Chapter 2, Dental
Record Retirement Tape
The annual verification section is located on the
right-hand side of the jacket and starts with the year
1996-2014. Leave this section blank. This block
should not be completed for dental records.
For records of non-military patients, a tentative
record retirement date (retirement year) should be
indicated on all dental records by attaching a colored
tape in the box marked Retired Year Tape on the
Figure 2-7.Data on inside front cover of the dental record jacket.