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Military Health System

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CS SCE 2875

Form/Template
10/27/2017

Form 2875 for access to Corporate Node

PDS Troubleshooting Feedback Form

Form/Template
10/23/2017

The PDS feedback form is available to MTF pharmacy point of contacts that have questions or concerns about the new PDS project. The form includes necessary fields for the PASS team to troubleshoot.

SCE AARF

Form/Template
10/4/2017

SAS COMPUTING ENVIRONMENT (SCE) Account Authorization Request Form (AARF)

CS SCE Access Instructions

Form/Template
10/4/2017

Instructions for completing the necessary forms to apply for a MDR user's account

VAERS Smallpox Pregnancy Supplemental Form

Form/Template
6/29/2017

Form for providers to refer patients who were exposed to smallpox vaccine while pregnant to the Smallpox Vaccine in Pregnancy Registry.

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Smallpox (ACAM2000) | Smallpox Vaccine-Associated Adverse Events | Pregnancy Information

Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA)

Form/Template
6/5/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA).

DOD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DOD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.

Protected Health Information Management Tool (PHIMT)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Protected Health Information Management Tool (PHIMT) system.

DHA-GL Worksheet-06: Surgical Pre-Authorization Request

Form/Template
4/10/2017

Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-06) This form is used to request pre-authroization for surgical care from the DHA, Great Lakes.

DHA-GL Worksheet-01: Medical Eligibility Verification

Form/Template
4/10/2017

Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
4/6/2017

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

DSADHA Certification Data Disposition 20180611

Form/Template
1/30/2017

This template is for the sole purpose of certifying that data used in connection with a Data Sharing Agreement (DSA) that was executed with the DHA Privacy and Civil Liberties Office (Privacy Office) has been appropriately disposed of in a timely manner.

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Data Sharing Agreements

DSA Change of Applicant/Recipient

Form/Template
1/30/2017

This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Applicant / Recipient listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Applicant / Recipient.

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Data Sharing Agreements

DSA Change of Government Sponsor

Form/Template
1/30/2017

This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Government Sponsor listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Government Sponsor.

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Data Sharing Agreements

DMRTI EWSC Registration Form

Form/Template
12/29/2016

Student enrollment form to register in the DMRTI EWSC Course

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Last Updated: October 22, 2021
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