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5/16/2023
Privacy impact assessment for 15th Medical Group, Hicham Air Force Base, March, 2023.
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5/2/2023
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Epidemiology and Analysis
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1/25/2023
Use this form to transfer Products or NDCs between Manufacturer Labelers, for billing purposes, in the TRICARE Retail Refund Program.
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).
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).
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.
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.
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.
Form/Template
1/3/2023
Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.
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.
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.
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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.
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.
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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).
Form/Template
10/24/2022
TRICARE Dispute Resolution Form for manufacturers. For use on resubmitted rejected disputes.
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Last Updated: July 26, 2022