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
Neurobehavioral Symptom Inventory Form
DHA Amazon Web Services
Medical Readiness Decision Support System (MRDSS)
DHA-GL Worksheet 01: Medical Eligibility Verification
Limited Duty Sailor and Marine Readiness Tracker MHS Application Access Gateways
Eisenhower AMC - Ft. Gordon MEDCOI
Patient Global Impression Change Scale
DHA Form 177: Potentially Compromised Temperature Sensitive Medical Report Worksheet
Medical Enterprise Data Integration and Collaboration
We found 616 items
Form/Template
July 29, 2014
Humana Military Healthcare Services Automated Information System (HMHS AIS)
.PDF |
71.90 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Humana Military Healthcare Services Automated Information System (HMHS AIS) system.
Form/Template
July 29, 2014
Clinical Information System (CIS)/Essentris ©
.PDF |
69.66 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Clinical Information System (CIS)/Essentris © system.
Form/Template
July 29, 2014
Health Net Federal Services Information System (HNFS IS)
.PDF |
74.37 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Health Net Federal Services Information System (HNFS IS) system.
Form/Template
July 29, 2014
Defense Medical Human Resources System - Internet (DMHRSi)
.PDF |
83.96 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Defense Medical Human Resources System - Internet (DMHRSi) system.
Form/Template
July 29, 2014
Delta Dental Federal Government Programs Information System (DDFGP-IS)
.PDF |
76.81 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Delta Dental Federal Government Programs Information System (DDFGP-IS) system.
Form/Template
July 29, 2014
Designated Provider Health Care Delivery System (DPHCDS)
.PDF |
80.86 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Designated Provider Health Care Delivery System (DPHCDS) system.
Form/Template
July 29, 2014
United Concordia Companies Inc. (UCCI) Active Duty Dental Program (ADDP)
.PDF |
99.80 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the United Concordia Companies Inc. (UCCI) Active Duty Dental Program (ADDP) system.
Form/Template
June 6, 2014
Plan of Action and Milestone Template
.PDF |
163.93 KB
This template is used to track plans of action and milestones regarding potential breaches.
Form/Template
June 1, 2014
Cosmetic Surgery Superbill 2014
.PDF |
292.24 KB
Use this form to bill for cosmetic surgery.
Form/Template
June 1, 2014
Formal Appeal Request
.PDF |
263.60 KB
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
April 30, 2014
Data Request Template (DRT) - Access by Login (all DHA Systems)
.XLSM |
25.81 KB
The Data Request Template for Access by Login for all DHA Systems is required for a Data Sharing Agreement Application.
Form/Template
April 30, 2014
General Data Request Template (DRT) Extractions (for all other DHA Systems)
.XLS |
98.00 KB
The Data Request Template for General Extractions is required for a Data Sharing Agreement Application.
Form/Template
April 16, 2014
MHS IM-IT Submissions Form Instructions
.DOCX |
259.79 KB
Instructions for completing the MHS IM-IT Submissions Form. The form is used to submit an idea that fosters a change to an IM/IT capability, policy/process, or system.
Form/Template
Oct. 1, 2013
MHS NoPP Acknowledgement Form
.PDF |
27.44 KB
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, ...
Form/Template
July 8, 2013
Neuroimaging following TBI in non deployed setting
.PDF |
485.60 KB
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, ...
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