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Military Health System

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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 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.

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.

Financial Management Information System

Form/Template
12/2/2022

Privacy Impact Assessment for the Financial Management Information System, an integrated resource execution system that enables the Military Health System Resource Management users to rapidly compile operational data from disparate internal and external legacy financial, acquisition, logistics, personnel, and payroll data sources.

Department of Defense Suicide Event Report

Form/Template
12/2/2022

Privacy Impact Assessment for the DoDSER 2.0, surveillance system designed to gather standardized risk and protective factor information for suicide events across multiple domains.

Armed Forces Health Longitudinal Technology Application (AHLTA)

Form/Template
11/15/2022

Privacy Impact Assessment for AHLTA, a fully integrated health care information system used in Department of Defense Military Treatment Facilities and clinics.

Pentax endoPRO iQ

Form/Template
11/10/2022

Pentax endoPRO iQ is a video and imaging application and the primary function is the maintenance/storage of patient and procedure data.

Joint Medical Operations Program Nomination/Registration Request

Form/Template
11/7/2022

This form is used to provide the Defense Medical Readiness Training Institute (DMRTI) with information required to complete course registration in order to provide student and DMRTI full course attendance as well as the awarding of Continuing Education credit (CME/CNE).

Recommended Content:

Defense Medical Readiness Training Institute | DMRTI Course Information | Joint Medical Operations Course | Joint Medical Planning Tool Course | Joint Senior Medical Leaders Course (JSMLC) | Joint Humanitarian Operations Course

TRICARE Dispute Resubmission Form

Form/Template
10/24/2022

TRICARE Dispute Resolution Form for manufacturers. For use on resubmitted rejected disputes.

340b Verification Form

Form/Template
10/24/2022

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

DHA Form 249: Pharmacy Data Warehouse Data Report Request Form

Form/Template
10/7/2022

Recommended Content:

DHA Pharmacy Operations Support Contract Data Management Team | CD-MART | D-MART | WTU P-MART

Web MEDCASE Requirements and Execution PIA

Form/Template
10/5/2022

The Web Medical Care Support Equipment (MEDCASE) Requirements and Execution (WebMRE) version 1.x system is a database and web application that is developed for the Defense Health Agency's (DHA's) Integrated Clinical Systems Program Management Office (ICS PMO). The WebMRE system is a Platform as a Service (PaaS) hosted on the DHA's Data Center Operations Branch (DCOPS) virtual environment. The WebMRE system is designed to provide detailed information, requirements data, and execution status to assist in the management and control of the MEDCASE/Super Capital Expense Equipment Program (SuperCEEP). WebMRE system will provide detailed information of Medical Device Equipment located in the Army's Medical Treatment Facilities (MTF’s) to assist with the requirements generation, life-cycle management and Planning, Programming, Budgeting and Execution (PPBE) process for Army Medical Equipment and general users. The system was a legacy application that was developed in Oracle 11g and was upgraded to Oracle 12c. The system was migrated from legacy application of Cold Fusion to ASP.NET MVC 5 Framework. The WebMRE System application is a database to manage the data captured via user interface. Front end of the application is developed using ASP.NET. The backend will use ORACLE 12c.

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Last Updated: October 18, 2022
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