AGFA NX Family of Systems (CR/DR) vNX27_A&I
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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Recent Forms & Templates
Image Management Systems Dental Imaging and Infrastructure
NeoLight Phoenix ICON v1.x_A&I
Reynolds AHC - Ft Sill MEDCOI
Vance MDG MEDCOI
Bio-Rad Variant II Hemoglobin Testing System Series v5.x A&I
Nihon Kohden Family of EEG Neurology & Sleep Devices V.12.x_A&A
Medtronic EndoFlip 300 System Series v3.x A&I
MHS GENESIS Electronic Health Record
Pharmacy Outpatient Automation Solution - iA
Popular Forms & Templates
Neurobehavioral Symptom Inventory Form
DHA-GL Worksheet 02: Pre-Authorization Request
DHA-GL Worksheet 01: Medical Eligibility Verification
Medical Readiness Decision Support System (MRDSS)
Patient Global Impression Change Scale
MHS Service Help Desk
Financial Management Information System
Siemens Somatom Somaris VB10X_A&I
MHS GENESIS Electronic Health Record
Limited Duty Sailor and Marine Readiness Tracker MHS Application Access Gateways
Form/Template
July 5, 2023
Siemens Dimension EXL 200 8.X A&I
.PDF |
727.10 KB
Siemens Dimension EXL 200 8.X A&I privacy impact assessment
Form/Template
June 28, 2023
Oculus Pentacam Device Family A&I
.PDF |
745.25 KB
Oculus Pentacam Device Family A&I privacy impact assessment
Form/Template
June 25, 2023
GE MAC VU360 Resting ECG Analysis System v1.02 A&I
.PDF |
769.04 KB
GE MAC VU360 Resting ECG Analysis System v1.02 A&I privacy impact assessment
Form/Template
June 12, 2023
340b Verification Form
.PDF |
203.71 KB
340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.
Form/Template
May 31, 2023
DHA DRT Quick Reference Guide
.PDF |
199.57 KB
Revised DSA Form - DSA Data Requests Templates Quick Reference Guide
Form/Template
May 31, 2023
De Identification Plan Template May 2023
.PDF |
154.64 KB
Use this updated template to provide the de-identification process to be used for your project. The plan should show how MHS sensitive data elements (or quasi-identifiers) will be de-identified as well as how the 18 HIPAA identifiers will be handled.
Form/Template
May 25, 2023
Expeditionary Medicine Platform Augmentation Readiness Training System
.PDF |
766.87 KB
Expeditionary Medicine Platform Augmentation Readiness Training System privacy impact assessment
Form/Template
May 21, 2023
Knowledge Exchange (Kx)
.PDF |
713.61 KB
Privacy Impact Assessment
Form/Template
May 17, 2023
72ND MDG TINKER AFB MEDCOI 508 COMPLIANT
.PDF |
737.49 KB
Privacy Impact Assessment, 72nd Medical Group (MDG) Tinker Air Force Base (AFB) Medical Community of Interest (MEDCOI).
Form/Template
May 17, 2023
66th MDG Hanscom AFB MEDCOI
.PDF |
736.57 KB
Privacy Impact Assessment 66th MDG Hanscom AFB MEDCOI.
Form/Template
May 17, 2023
Nihon Kohden Polysmith Sleep System A&A
.PDF |
651.97 KB
Nihon Kohden Polysmith Sleep System A&A privacy impact assessment
Form/Template
May 17, 2023
Siemens Rapid Point Version 5.X A&I
.PDF |
730.12 KB
Siemens Rapid Point Version 5.X A&I privacy impact assessment
Form/Template
May 17, 2023
Naval Health Clinic Annapolis MEDCOI Privacy Impact Assessment
.PDF |
764.07 KB
Naval Health Clinic Annapolis MEDCOI Privacy Impact Assessment, March 2023.
Form/Template
May 15, 2023
Beckman Coulter AU5800 v5.X A&I
.PDF |
693.94 KB
Beckman Coulter AU5800 v5.X A&I privacy impact assessment
Form/Template
May 2, 2023
AFHSD 501 Request Form
.PDF |
311.80 KB
Armed Forces Health Surveillance Division (AFHSD) Epidemiology and Analysis AFHSD 501 Request Form
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