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Military Health System

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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 two 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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72ND MDG TINKER AFB MEDCOI 508 COMPLIANT

Form/Template
5/17/2023

Privacy Impact Assessment, 72nd Medical Group (MDG) Tinker Air Force Base (AFB) Medical Community of Interest (MEDCOI).

Imagine Dental Workstation WIN10 AI Privacy Impact Assessment

Form/Template
5/17/2023

Imagine Dental Workstation WIN10 AI Privacy Impact Assessment, March 2023.

DRAEGER INFINITY DELTA SERIES

Form/Template
5/17/2023

Privacy Impact Assessment, Draeger Infinity Delta Series AI.

Defense Medical Accessions Computing System Privacy Impact Assessment

Form/Template
5/17/2023

Defense Medical Accessions Computing System Privacy Impact Assessment, March 2023.

Enterprise Clinical Audiology Application Privacy Impact Assessment

Form/Template
5/17/2023

Enterprise Clinical Audiology Application Privacy Impact Assessment, March 2023.

Automated Information Discovery Environment Medical Common Operating Picture (AIDE MedCOP)

Form/Template
5/17/2023

Privacy Impact Assessment, Automated Information Discovery Environment Medical Common Operating Picture (AIDE MedCOP).

Naval Health Clinic Annapolis MEDCOI Privacy Impact Assessment

Form/Template
5/17/2023

Naval Health Clinic Annapolis MEDCOI Privacy Impact Assessment, March 2023.

15th MDG Hickam AFB MEDCOI Privacy Impact Assessment

Form/Template
5/16/2023

Privacy impact assessment for 15th Medical Group, Hicham Air Force Base, March, 2023.

AFHSD 501 Request Form

Form/Template
5/2/2023

Armed Forces Health Surveillance Division (AFHSD) Epidemiology and Analysis AFHSD 501 Request Form

TRICARE Retail Refund NDC Transfer Form

Form/Template
1/25/2023

Use this form to transfer Products or NDCs between Manufacturer Labelers, for billing purposes, in the TRICARE Retail Refund Program.

DHA DSA Modification Request - Data Sharing Agreements

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).

DSA Extension Request - Data Sharing Agreements

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).

DHA DSAA Prerequisite Checklist - Data Sharing Agreements

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.

DHA Renewal Request - Data Sharing Agreement

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.

DHA DSA Application - Data Sharing Agreement

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.

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Last Updated: July 11, 2023
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