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Form/Template
6/1/2014
Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-03) Complete this form when submitting a formal appeal for denied medical claims or denied pre-authorization requests by the DHA, Great Lakes.
Form/Template
5/19/2014
Used to obtain information/specimens needed to evaluate and document forensic DNA testing.
Form/Template
4/30/2014
The Data Request Template for Access by Login for all DHA Systems is required for a Data Sharing Agreement Application.
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Data Sharing Agreements
Form/Template
4/30/2014
The Data Request Template for General Extractions is required for a Data Sharing Agreement Application.
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Data Sharing Agreements
Form/Template
4/8/2014
Defense Health Agency (DHA) Office of Small Business Programs (OSBP) uses the System for Award Management (SAM), as well as other government-wide procurement systems, such as the Federal Procurement Data Systems (FPDS), to compile data on Small Business (SB) vendors. The information gathered assists in identifying vendors, their capabilities, and other information necessary for potential contracting opportunities with DHA. The below information captures such information and is used only to assist within the identification process. Completing and submitting this form is voluntary. DHA does not guarantee that your company will be selected for, or awarded a contract to provide products or services.
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Small Business Programs | Small Business Programs
Form/Template
2/27/2014
The Researcher Responsibilities Form ensures that all investigators conducting Department of Defense (DoD) research involving human participants understand and comply with all the relevant federal and DoD regulations, including Human Protections, records management, and the Health Insurance Portability and Accountability Act (HIPAA). The form also includes provisions related to any DoD biomedical research to comply with FDA regulations.
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Research and Innovation
Form/Template
12/1/2013
Form used to request access to the collections at the National Museum of Health and Medicine.
Form/Template
10/1/2013
The MHS Notice of Privacy Practices (NoPP) describes how medical information about you may be used and disclosed and how you can get access to this information. This form serves as an acknowledgement to patients and beneficiaries that they have received the MHS NoPP. The template is sized to scale and can be reproduced locally on Avery Label #5163, 5263, 2163, 5923, 5963 (size: 2 inches x 4 inches).
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How HIPAA Protects You | HIPAA Compliance within the MHS | MHS Notice of Privacy Practices
Form/Template
7/8/2013
The guidance contained in this CR represents a review of currently published literature and expert contributions obtained by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) in collaboration with clinical subject matter experts representing the Services, Department of Veterans Affairs (VA), academic, research and civilian sectors.
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Health Readiness & Combat Support | Conditions and Treatments | Disability Evaluation | Traumatic Brain Injury
Form/Template
7/1/2013
Use this form to bill for cosmetic surgery.
Form/Template
8/1/2012
Use this form if a Research Authorization Review template and an Authorization are approved by the DHA Privacy Board, a PI will be required to sign a Principal Investigator Certification. Among other requirements, the certification ensures that the PI will maintain, electronically and/or in hard copy, the signed Authorization for each research participant whose PHI is used or disclosed in the project, and will provide any and/or all of the signed Authorizations to DHA immediately upon request.
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Privacy Board
Form/Template
8/1/2012
Use this form if the researcher intends to conduct a review of PHI to prepare for a research protocol or for similar purposes preparatory to research (e.g., for recruitment or screening purposes) and agrees not to remove the PHI from DHA, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and DoD 6025.18-R.
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Privacy Board
Form/Template
8/1/2012
Use this form if the researcher intends to obtain HIPAA Authorizations, also known as “Authorizations,” from research participants to comply with the HIPAA Privacy Rule, the PI must submit to the DHA Privacy Board a copy of the blank Authorization(s) to be used in the project and the completed Research Authorization Review. The DHA Privacy Board will conduct a review to determine that all core elements and required statements are provided in the Authorization(s) as required by the HIPAA Privacy Rule and DoD 6025.18-R.
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Privacy Board
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