Military Health System

TRICARE Retail Refund NDC Transfer Form

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

DSA Extension Request - Data Sharing Agreements

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 DSA Modification Request - Data Sharing Agreements

This template shall be used to modify an executed Data Sharing Agreement (DSA) that incorporates an approved Data Sharing Agreement Application (DSAA).

DHA DSAA Prerequisite Checklist - Data Sharing Agreements

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

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

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.

Request for Autopsy Report and Supplemental Information

Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.

Department of Defense Suicide Event Report

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.

Financial Management Information System

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.

Armed Forces Health Longitudinal Technology Application (AHLTA)

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

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

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).

340b Verification Form

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

TRICARE Dispute Resubmission Form

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

DHA Form 249: Pharmacy Data Warehouse Data Report Request Form