Transmittal Notice 67-65
The attached material is forwarded to replace those pages in Part 3, Chapter 2 of June 3, 1966 (TN No. 57) which were marked for later replacement by sample forms.
/E.S. Rabeau, M.D./
E.S. Rabeau, M.D.
Assistant Surgeon General
Director, Division of Indian Health
Part 3, Chapter 2, Appendix II:
Page 14a, Sample Form PHS-2056-1, Patient Epidemiology and Service Record
Pages 18a & 18b, Sample Form PHS-2964, Authorization for and Report of Contract Dental Care
Page 21a, Sample Form PHS-2506-2, Page 1, Dental Epidemiology and Service Report
Page 21b, Sample Form PHS-2506-2, Page 2, Master Mark Form 12
Page 26a, Sample Form PHS-2506-3, Page 1, Orthodontic Examination and Report
Page 26b, Sample Form PHS-2506-3, Page 2, Master Mark Form 13
Page 35a & 35b, Sample Form PHS-2506-4, Interceptive Orthodontic Register Record.
"Marker" pages for the above material.
Substitute the attached pages for the superseded ones. Discard the superseded pages.
Distribution: P-ABCDG under d, B, C under d
Date: January 3, 1967
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