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
March 28, 2023
81st MDG Keesler AFB MEDCOI
.PDF |
741.21 KB
Privacy Impact Assessment, 81st Medical Group (MDG) Keesler Air Force Base (AFB) Medical Community of Interest (MEDCOI).
Form/Template
March 21, 2023
Clinical Information System - .mil Enclave
.PDF |
741.62 KB
Privacy Impact Assessment, Clinical Information System .mil Enclave
Form/Template
March 21, 2023
Online Base of Information Widely Accessible over Network OBIWAN
.PDF |
731.84 KB
Privacy Impact Assessment
Form/Template
March 21, 2023
Philips DigiTrak XT Recorder - Holter System v3.X A&I
.PDF |
731.84 KB
Philips DigiTrak XT Recorder - Holter System v3.X A&I privacy impact assessment
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
March 14, 2023
Automated Information Discovery Environment Medical Common Operating Picture
.PDF |
656.01 KB
Privacy Impact Assessment, Automated Information Discovery Environment Medical Common Operating Picture (AIDE MedCOP).
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
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
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 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."
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