Dd Form 2807-2 - Accessions Medical Prescreen Report Page 5
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7LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION III - APPLICANT COMMENTS
(Continued).
SECTION IV - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION:
Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information.
Attach additional sheets if necessary.
1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
DD FORM 2807-2, MAR 2015
Page 5 of 7 Pages
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