Navy Medical Center San Diego MEDCOI
Forms & Templates
On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.
Please note that files more than five years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.
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Popular Forms & Templates
DHA-GL Worksheet 02: Pre-Authorization Request
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Patient Global Impression Change Scale
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We found 616 items
Form/Template
March 14, 2023
Draeger Infinity Delta Series A&I
.PDF |
745.91 KB
Draeger Infinity Delta Series A&I privacy impact assessment
Form/Template
Jan. 25, 2023
TRICARE Retail Refund NDC Transfer Form
.PDF |
345.00 KB
Use this form to transfer Products or NDCs between Manufacturer Labelers, for billing purposes, in the TRICARE Retail Refund Program.
Form/Template
Jan. 13, 2023
DSA Extension Request - Data Sharing Agreements
.PDF |
161.28 KB
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
Jan. 13, 2023
DHA DSA Modification Request - Data Sharing Agreements
.PDF |
582.59 KB
This template shall be used to modify an executed Data Sharing Agreement (DSA) that incorporates an approved Data Sharing Agreement Application (DSAA).
Form/Template
Jan. 13, 2023
DHA DSAA Prerequisite Checklist - Data Sharing Agreements
.PDF |
1.06 MB
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 ...
Form/Template
Jan. 5, 2023
DHA DSA Application - Data Sharing Agreement
.PDF |
3.58 MB
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
Jan. 5, 2023
DHA Renewal Request - Data Sharing Agreement
.PDF |
307.35 KB
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
Dec. 15, 2022
Masimo Rad 5 Pulse Oximeter
.PDF |
712.44 KB
Privacy Impact Assessment
Form/Template
Oct. 24, 2022
TRICARE Dispute Resubmission Form
.PDF |
232.17 KB
TRICARE Dispute Resolution Form for manufacturers. For use on resubmitted rejected disputes.
Form/Template
Oct. 7, 2022
DHA Form 249: Pharmacy Data Warehouse Data Report Request Form
.PDF |
36.10 KB
DHA Form 249: Pharmacy Data Warehouse Data Report Request Form. To download the form , right-click and select "Save Link As". To open the form, right-click and select "Open with Adobe Acrobat."
Form/Template
Oct. 4, 2022
Web MEDCASE Requirements and Execution 1.x A&A 2990
.PDF |
755.20 KB
Web MEDCASE Requirements and Execution 1.x A&A 2990 privacy impact assessment
Form/Template
July 21, 2022
Enterprise Patient Queuing and Notification System (ePQNS)
.PDF |
678.33 KB
The Enterprise Patient Queuing Notification System (ePQNS) automates patient check-in during visits to Military Treatment Facilities (MTFs) and clinics. ePQNS provides real-time information to leadership to manage assets as wait-times increase or the situation dictates. It also allows MTFs to determine inefficiencies, identify best practices, and ...
Form/Template
July 6, 2022
Navy Medicine Operational Training Command MEDCOI
.PDF |
737.69 KB
Navy Medicine Operational Training Command Medical Community of Interest privacy impact assessment
Form/Template
March 21, 2022
Assistance Reporting Tool (ART)
.PDF |
704.13 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Assistance Reporting Tool (ART) system.
Form/Template
March 10, 2022
Armed Forces Billing and Collection Utilization Solution - Amazon Web Services
.PDF |
771.75 KB
The Armed Forces Billing and Collection Utilization Solution (ABACUS) provides a standard patient accounting system for health care billing practices.
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