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Military Health System

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DHA Privacy Office Standard Contract Language

Form/Template
10/27/2020

This Section addresses the Contractor’s requirements under The Privacy Act of 1974 (Privacy Act), The Freedom of Information Act (FOIA), and The Health Insurance Privacy and Accountability Act (HIPAA) as set forth in applicable statutes, implementing regulations and DOD issuances.

Recommended Content:

Privacy and Civil Liberties | Privacy Contract Language

HIPAA Safeguard Review of Non-Federal Systems (HSR)

Form/Template
10/1/2020

The HIPAA Safeguard Review of Non-Federal Systems (HSR) is used when data obtained through a DSAA will be stored, transmitted, processed, or otherwise maintained on a non-federal information system.

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Data Sharing Agreements

Dental Common Access System

Form/Template
9/2/2020

Dental Common Access System (DENCAS)

MDR Special Justification Form

Form/Template
4/1/2020

Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.

DD Form 3111: Routine Immunization Screening Form: Adults

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for adults.

DD Form 3110: Routine Immunization Screening Form: Pediatric

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for children and teens.

Smallpox Vaccine Screening Form

Form/Template
3/2/2020

Each potential recipient of smallpox vaccine must complete this official screening form and it must be signed by a licensed health care provider prior to vaccination.

Recommended Content:

Smallpox (ACAM2000) | Smallpox Vaccine-Associated Adverse Events

AFRSSIR Supply Order Request

Form/Template
2/12/2020

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

Recommended Content:

Armed Forces Medical Examiner System | Forensic Pathology Investigations (FPI) | DOD DNA Operations | Repository of Specimen Samples for the Identification of Remains

DMRTI JOP Student Nomination_JAN20

Form/Template
1/22/2020

Student nomination form for both JMOCs and JMPT.

Form 543

Form/Template
1/2/2020

DMRTI JOP Student Nomination

Form/Template
12/11/2019

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

AFHSB 501 Request Form

Form/Template
11/26/2019

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form

DHA-GL Worksheet 41: DOD/VA MOA Inpatient-Outpatient Continued Stay Review

Form/Template
11/20/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

EACE Data Request Form

Form/Template
11/20/2019

Form for users to fill out to request information/data from EACE

DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization VAMC Richmond Only

Form/Template
11/14/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

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Last Updated: September 13, 2022
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