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Kimbrough Ambulatory Care Center
Kimbrough Ambulatory Care Center
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TRICARE
DECEMBER FLU DRIVE DATE - 6 DEC!
Flu vaccines will be available at McGill Dec. 6 from 10 AM to 6 PM for active duty and TRICARE beneficiaries enrolled at a military facility (not enrolled in US Family Health or Johns Hopkins).
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Kimbrough Ambulatory Care Center Forms
DA Form 4036 - Medical and Dental Preparation for Overseas Movement
DA Form 5018-R - ADAPCP Client's Consent Statement for Release of Treatment Information
DA Form 5118 - Reassignment Status and Election Statement (Enlisted Soldiers only)
DA Form 7708 - Personnel Reliability Screening & Evaluation
DD Form 2697 - Report of Medical Assessment
DD Form 2807-1 - Report of Medical History
DD Form 2808 - Report of Medical Examination
DD Form 2870 - Authorization for Disclosure of Medical or Dental Information
Exceptional Family Member Program Travel Screening Form Instructions
MEDDAC Form 700 - KACC Full Registration Information
NAVMED 1300/1 - Medical, Dental, and Educational Suitability Screening for Service and Family Members
NAVMED 1300/2 - Medical, Dental, and Educational Suitability Screening Checklist and Worksheet
NAVMED 1300/4 - Expeditionary Medical and Dental Screening For Individual Augmentee(IA) and Support Assignments to Overseas Contingency Operations (OCO)
NAVMED 6110/4 - Physical Fitness Assessment Medical Clearance/Waiver
NAVPERS 1300/16 - Report of Suitability for Overseas Assignment
Defense Health Agency Forms
DHA Form 236: Pediatric (6 months-11 years) COVID-19 Vaccine Screening and Immunization
DHA Form 207: COVID-19 Vaccine Screening and Immunization Document
TRICARE Forms
Download a TRICARE Form
Third Party Collection Program
Third Party Collection Program DD Form 2569
The Third Party Collection Program (TPCP) requires Military Treatment facilities (MTF) to bill your Other Health Insurance (OHI) for Outpatient visits or Inpatient stays. If you have Tricare
AND
other health insurance coverage, the government requires that we attempt to collect payment from your third party insurance. In addition to fling claims for office visit and inpatient stays we also bill your insurance for all ancillary services provided such as Pharmacy, Laboratory and Radiology services.
The key to the Third Party Collection Program’s success is you and the OHI coverage that you or your spouse may be paying for, but are not using. We require that you fill out and submit your OHI information on a DD2569 for processing. This should be done annually or upon any change to your coverage. We will then bill your insurance company directly for the cost of your visit.
Who must participate in the Third Party Collection Program?
Tricare members who have Other Health Insurance:
Family Members of Active Duty
Retired Military Members
Family Members of Retired Members
Collectively these categories of patients are called "DoD Beneficiaries"
Where does the money go?
Payments from your healthcare insurer go directly to our Medical Treatment Facility's operating budget. The money is then used to enhance the total healthcare services offered to you.
How can you help us?
Complete DD Form 2569
Turn the form in to the Patient Administration Division (PAD) office or drop off at the front desk during your next PCM visit.
Update your information with PAD or your clinic whenever there is a change to your insurance coverage (e.g. carriers, policy, address or phone number).
Don't forget to keep your family's information up-to-date in
DEERS
.