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Military Health System

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TRICARE Dispute Resubmission Form

Form/Template
9/28/2022

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

TRICARE Retail Refund NDC Transfer Form

Form/Template
9/28/2022

Use this form to transfer or make changes to your current Appendix A

340b Verification Form

Form/Template
9/28/2022

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

59th MDW Wilford Hall WHEN MEDCOI PIA

Form/Template
9/20/2022

The 59th MDW Wilford Hall (WHEN)_MEDCOI is also known as Wilford Hall Ambulatory Surgical Center (WHASC) Site and Wilford Hall Enterprise Network (WHEN) is an outpatient Medical Treatment Facility (MTF) supporting over 240,000 enrolled Tri-Service Beneficiaries and more than 6,000 military members, civilian personnel, residents, and students. The WHEN Enclave consists of End User Devices (EUDs), switches, appliances, and the data center. The WHEN provides all environmental controls such as light, power, Heating Ventilation Air Conditioning, and physical security for the data center. Co-located and Managed Co-located systems within the data center include systems and applications that contain Protected Health Information (PHI) and Personally Identifiable Information (PII) data. Data Network Connectivity (DNC), Enterprise Management System (EMS), and the Network Protection Suite are services controlled and managed by DHA and are not included in the authorization boundary.

DHA Form 116: Pediatric and Adult Influenza Screening and Immunization Documentation

Form/Template
9/14/2022

A form for screening both children and adults for contraindications to receiving influenza vaccine. (v3, September 2022)

Recommended Content:

Immunizations | Influenza, Northern Hemisphere | Influenza, Southern Hemisphere

DHA Form 207: COVID-19 Vaccine Screening and Immunization Document v22

Form/Template
9/9/2022

The purpose of this form is to determine if the COVID-19 vaccine can be administered to the patient. (v22, Sept. 2022)

Recommended Content:

Coronavirus and the COVID-19 Vaccine | Immunization Healthcare Division | COVID-19 Vaccine Efforts | COVID-19 Information for Military Treatment Facility Directors | Coronavirus

BUMED Manpower Information System II BUMIS II PIA

Form/Template
9/8/2022

BUMIS II provides an online inventory of personnel assigned to Navy Medicine. It includes demographics, education, health care specialty, additional qualifications, assignment and training skills. BUMIS II provides personnel planners at headquarters level with data about the medical personnel force that allows tracking and trends of gains, losses, and skill mix. The data is pivotal for the development of personnel strength plans, promotion plans, accession plans, and training plans and is also used for ad hoc queries responding to inquiries about Medical Department Officer force from both inside and outside the Navy Medical department.

Clinical Information System CIS Essentris Inpatient System PIA

Form/Template
9/8/2022

Clinical Information System (CIS)/Essentris® Inpatient System (hereinafter “CIS Essentris®”) the Military Health System (MHS) inpatient documentation solution is a comprehensive clinical documentation system for use in acute care hospitals. CIS/Essentris® enables continuous and automated clinical documentation and bedside point-of-care data capture. All inpatient clinical documentation is created and stored in CIS/Essentris®, the Composite Health Care System (CHCS), and bedside instruments. Clinical data may be aggregated, trended, and analyzed to manage care for a single patient or for an entire patient population. CIS/Essentris® also provides waveform documentation, graphical trending on patient parameters, a reference library, patient education materials, and various reporting capabilities such as change of shift reports, task lists, and administrative reports.

Workload Management System for Nursing Internet WMSNi PIA

Form/Template
9/8/2022

The purpose of the WMSNi system is to determine the nursing manpower requirements based upon patient care needs. The patient acuity data is collected to analyze nurse personnel requirements to meet the clinical needs of active service members, their families, retirees and other DOD personnel and dependents. WMSNi determines how many staff members are needed on a particular nursing unit to provide care during a 24-hour period. The resulting nursing manpower requirements are then documented in a table of distribution and allowances for use at the US Army Medical Command and its Medical Treatment Facilities (MTFs). Along with US Army MEDCOM and its MTFs, WMSNi is also being utilized at Walter Reed National Military Medical Center (WRNMMC), which is under the control of the Defense Health Agency (DHA).

DHA Form 177: Potentially Compromised (PC) Temperature Sensitive Medical Product (TSMP) Worksheet

Form/Template
9/1/2022

TSMP collectively refers to: vaccines, some pharmaceuticals, temperature sensitive laboratory supplies, and other temperature sensitive medical items.

Access Controls June 2022

Form/Template
8/31/2022

Access Controls Information Paper, updated June 2022

Best Practices for Safeguarding Laptops June 2022

Form/Template
8/31/2022

Information Paper on Best Practices for Safeguarding Laptops, updated June 2022

Best Practices for Verification of Identity June 2022

Form/Template
8/31/2022

Best Practices for Verification of Identity Information Paper, updated June 2022

Administrative Safeguards June 2022

Form/Template
8/31/2022

Administrative Safeguards Information Paper, updated June 2022

Military Health System Information Platform PIA

Form/Template
8/23/2022

The Military Health Systems (MHS) Information Platform (MIP) is a system containing multiple dashboards and databases that deliver enterprise clinical data capabilities. The capabilities provided by MIP are: Program Management; Data Warehousing; Application Portal; Infrastructure and Operations; Application Support; Business Intelligence; Analytics; Predictive Analytics; Legacy Data Consolidation Service; Defense Medical Surveillance System; and Corporate Executive Information System. Types of projects enabled by MIP include clinical dashboards, reports, data feeds, ad-hoc data requests, a data mart, medical history tracking of individual service members, and identification of service members at elevate risk of injury or mental health illness.

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Last Updated: October 22, 2021
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