DD Form 2813 "Department of Defense Active Duty/Reserve/Guard/Civilian Forces Dental Examination"

What Is DD Form 2813?

DD Form 2813 - Department of Defense Active Duty/Reserve/Guard/Civilian Forces Dental Examination is a form used for gathering dental information on service members about to spend an extended period of time away without of access to dental services.

The DD 2813 - or the Military Dental Form - is completed by the dental treatment facility (DTF) or civilian provider and the gathered information is stored within personnel medical files. The related Standard Form 603, Health Record - Dental can be used for the same purposes.

The examination form - often incorrectly referred to as the DA Form 2813 - was revised by the Department of Defense (DoD) on November 1, 2021. A fillable copy of the DD Form 2813 can be downloaded below or can be supplied through the chain of command.

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Military Dental Form Instructions

The Government requires that all Active Duty and Reserve members receive annual dental examinations. The examination results documented on the DD 2813 Form help military physicians determine if a soldier is fit for extended service away from dental help.

The DD 2813 dental form is filled out both by the soldier receiving the dental examination and by the dentist providing it - you must bring the form with you to the examination and hand it to your doctor. Your dentist has to sign the form after the dental tests are over.

  1. Fill in your basic identifying data in Boxes 1 through 5. This includes your full name, social security number, branch of service, your unit of assignment and its address. The rest of the form will is filed by your doctor.
  2. The dentist will describe your dental condition by selecting one of the options in Box 6.
  3. In case your doctor discovers a condition that might result in an emergency in the following 12 months, they must describe it by selecting an applicable option in Box 6 (3) and give a brief written summary of the condition in Box 6 (4).
  4. Any X-rays that were performed during the examination should be marked in Box 6 (5).
  5. Boxes 7, 8 and 9 are reserved for your dentist's contact information: their full name, telephone number, address, signature and signature's license number.
  6. The doctor has to date the form in Box 10.

Army Dental Readiness Classes

The soldier is given a dental readiness class based on the results of the DD 2813 dental form. There are four readiness classes in total.

  • Class I is given to soldiers with perfect oral hygiene who are not expected to require dental treatment or re-evaluation for the next 12 months.
  • Class II is given to soldiers who have oral conditions that, if not treated or followed up, have the potential but are not expected to result in a dental emergency. These soldiers might have some history of periodontal disease but are currently in stable condition.
  • Class III is given to soldiers whose dental health is in poor condition or soldiers who have some oral conditions that are expected to result in dental emergencies within 12 months if not treated. In case of any confusion in choosing between the second and third dental readiness class, the doctor must choose the more severe of the two.
  • Class IV is given to any soldiers that have had no oral examination in the last 13 months.
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Download DD Form 2813 "Department of Defense Active Duty/Reserve/Guard/Civilian Forces Dental Examination"

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CUI when filled
OMB No. 0720-0022
DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN
OMB approval expires
FORCES DENTAL EXAMINATION
20230131
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.
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:
IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)
(5) Were X-rays consulted?
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)
Controlled by: DHA
PREVIOUS EDITION IS OBSOLETE.
DD FORM 2813, NOV 2021
CUI Category: PRVCY
CUI when filled
LDC: FEDCON
POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@mail.mil
CUI when filled
OMB No. 0720-0022
DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE/GUARD/CIVILIAN
OMB approval expires
FORCES DENTAL EXAMINATION
20230131
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.
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:
IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)
(5) Were X-rays consulted?
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)
Controlled by: DHA
PREVIOUS EDITION IS OBSOLETE.
DD FORM 2813, NOV 2021
CUI Category: PRVCY
CUI when filled
LDC: FEDCON
POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@mail.mil