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Active Duty Dental Program Forms

Appointment of Appeal Representative

Active duty service members in remote locations may appeal a claim denial by contacting United Concordia in writing. If you would like to authorize another individual to file a claim on your behalf (e.g., spouse or other family member), complete the Authorization to Appeal and submit it to United Concordia. You must complete the Request and Authorization for Disclosure of Health Information (HIPAA Release) form and the Appointment of Individual to Act as Appeal Representative Form. Both forms must be received and completed entirely before an appeal can be processed.

Appointment Request Form

This form is for active duty service members in remote locations who do not need authorization to receive private sector dental care. You must submit this form and receive an Appointment Control Number (ACN) from United Concordia before receiving private sector dental care.

Claim Form

United Concordia's network dentists will file a claim on your behalf. If you are approved to utilize a non-network dentist, you may be required to submit your own claim form. Mail your completed form and supporting documentation to:

United Concordia
Claims Processing
P.O. Box 69429
Harrisburg, PA 17106-9429

Department of Defense Active Duty/Reserve Forces Dental Examination Form (DD Form 2813)

This form is used to used to assist active duty and National Guard and Reserve members in documenting dental health for worldwide duty. It should be downloaded and given to the dental provider to complete.

Fraud Complaint Form

If you believe a dentist or entity has received insurance money through the submission of a false claim, you should report this information to the Special Investigations Unit (SIU).

United Concordia Companies, Inc.
Special Investigations Unit
4401 Deer Path Road, DP-4F
Harrisburg, PA 17110

Fax: 1-717-260-7240

Grievance Form

If you would like to submit a concern regarding a quality of care issue, complete the attached form and return it to United Concordia's Grievance Unit.

United Concordia
ADDP Grievances
4401 Deer Path Road, DP-4J
Harrisburg, PA 171110-3907

Fax: 1-717-260-7168

Request and Authorization for Disclosure of Health Information

This form should be completed to release PHI between spouses, for children 18 years and older or any other person not authorized to receive information without written authorization. This is necessary due to HIPAA Privacy Regulations.

Last Updated 12/9/2013