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Military Health System

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Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.

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15th MDG Hickam AFB MEDCOI Privacy Impact Assessment

Form/Template
5/16/2023

Privacy impact assessment for 15th Medical Group, Hicham Air Force Base, March, 2023.

AFHSD 501 Request Form

Form/Template
5/2/2023

Armed Forces Health Surveillance Division (AFHSD) Epidemiology and Analysis AFHSD 501 Request Form

TRICARE Retail Refund NDC Transfer Form

Form/Template
1/25/2023

Use this form to transfer Products or NDCs between Manufacturer Labelers, for billing purposes, in the TRICARE Retail Refund Program.

DHA DSA Modification Request - Data Sharing Agreements

Form/Template
1/13/2023

This template shall be used to modify an executed Data Sharing Agreement (DSA) that incorporates an approved Data Sharing Agreement Application (DSAA).

DSA Extension Request - Data Sharing Agreements

Form/Template
1/13/2023

This template shall be used to request a 30 day extension in order to continue to use the data in accordance to the executed Data Sharing Agreement (DSA).

DHA DSAA Prerequisite Checklist - Data Sharing Agreements

Form/Template
1/13/2023

This checklist is designed to ensure you have completed the Data Sharing Agreement Application (DSAA) pre-submission reviews and have the necessary documentation to submit a DSAA. You must complete and submit this Prerequisite Checklist (PRC) to the Defense Health Agency (DHA) Privacy and Civil Liberties Office (PCLO) before you submit a DSAA or it will be declined.

DHA DSA Application - Data Sharing Agreement

Form/Template
1/5/2023

This template is used to assist the Defense Health Agency (DHA) Privacy and Civil Liberties Office (Privacy Office) with its consideration of prospective data uses involving DHA data.

DHA Renewal Request - Data Sharing Agreement

Form/Template
1/5/2023

This template shall be used to renew an executed Data Sharing Agreement (DSA) that incorporates an approved Data Sharing Agreement Application (DSAA). Submit this completed request or questions to the DHA Privacy and Civil Liberties Office (Privacy Office) at dha.ncr.j-6.mbx.dsa-mail@health.mil.

Request for Autopsy Report and Supplemental Information

Form/Template
1/3/2023

Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.

Department of Defense Suicide Event Report

Form/Template
12/2/2022

Privacy Impact Assessment for the DoDSER 2.0, surveillance system designed to gather standardized risk and protective factor information for suicide events across multiple domains.

Financial Management Information System

Form/Template
12/2/2022

Privacy Impact Assessment for the Financial Management Information System, an integrated resource execution system that enables the Military Health System Resource Management users to rapidly compile operational data from disparate internal and external legacy financial, acquisition, logistics, personnel, and payroll data sources.

Armed Forces Health Longitudinal Technology Application (AHLTA)

Form/Template
11/15/2022

Privacy Impact Assessment for AHLTA, a fully integrated health care information system used in Department of Defense Military Treatment Facilities and clinics.

Pentax endoPRO iQ

Form/Template
11/10/2022

Pentax endoPRO iQ is a video and imaging application and the primary function is the maintenance/storage of patient and procedure data.

Joint Medical Operations Program Nomination/Registration Request

Form/Template
11/7/2022

This form is used to provide the Defense Medical Readiness Training Institute (DMRTI) with information required to complete course registration in order to provide student and DMRTI full course attendance as well as the awarding of Continuing Education credit (CME/CNE).

TRICARE Dispute Resubmission Form

Form/Template
10/24/2022

TRICARE Dispute Resolution Form for manufacturers. For use on resubmitted rejected disputes.

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Last Updated: July 19, 2022
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