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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.

If you're having trouble finding what you're looking for, consider using fewer words in your search criteria. Results are limited to content that matches all terms in the search field.

DHA Small Vendor Business Profile List

Form/Template
4/8/2014

Defense Health Agency (DHA) Office of Small Business Programs (OSBP) uses the System for Award Management (SAM), as well as other government-wide procurement systems, such as the Federal Procurement Data Systems (FPDS), to compile data on Small Business (SB) vendors. The information gathered assists in identifying vendors, their capabilities, and ...

Recommended Content:

Doing Business with DHA OSBP | Small Business Programs

Researcher Responsibilities

Form/Template
2/27/2014

The Researcher Responsibilities Form ensures that all investigators conducting Department of Defense (DoD) research involving human participants understand and comply with all the relevant federal and DoD regulations, including Human Protections, records management, and the Health Insurance Portability and Accountability Act (HIPAA). The form also ...

Recommended Content:

Research and Innovation

Collections Access Request

Form/Template
12/1/2013

Form used to request access to the collections at the National Museum of Health and Medicine.

MHS NoPP Acknowledgement Form

Form/Template
10/1/2013

The MHS Notice of Privacy Practices (NoPP) describes how medical information about you may be used and disclosed and how you can get access to this information. This form serves as an acknowledgement to patients and beneficiaries that they have received the MHS NoPP. The template is sized to scale and can be reproduced locally on Avery Label #5163, ...

Recommended Content:

How HIPAA Protects You | HIPAA Compliance within the MHS | Notice of Privacy Practices

Neuroimaging following TBI in non deployed setting

Form/Template
7/8/2013

The guidance contained in this CR represents a review of currently published literature and expert contributions obtained by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) in collaboration with clinical subject matter experts representing the Services, Department of Veterans Affairs (VA), academic, ...

Recommended Content:

Health Readiness | Conditions and Treatments | Physical Disability | Traumatic Brain Injury

Cosmetic Surgery Superbill 2013

Form/Template
7/1/2013

Use this form to bill for cosmetic surgery.

DD Form 2959: Breach of Personally Identifiable Information (PII) Report

Form/Template
2/1/2013

This form is used to report and provide information on lost, stolen, or compromised personally identifiable information (PII).

Recommended Content:

Breaches of PII and PHI

DCoE Concussion Management Algorithm Cards

Form/Template
10/8/2012

Combat Medic/Corpsman Algorithm Card to diagnose a concussion in a deployed setting

Recommended Content:

Conditions and Treatments | Physical Disability | Traumatic Brain Injury | Health Readiness

DHA Privacy Board Application for a Waiver of Authorization or an Altered Authorization

Form/Template
8/1/2012

Use this form if the researcher has not received documentation from an Institutional Review Board (IRB) or HIPAA Privacy Board approving a waiver or alteration of Authorizations and reasons exist that make it impractical or impossible for the researcher to obtain Authorizations from each research participant, the PI may submit an Application for a ...

Recommended Content:

Privacy Board

Principal Investigator Certification

Form/Template
8/1/2012

Use this form if a Research Authorization Review template and an Authorization are approved by the DHA Privacy Board, a PI will be required to sign a Principal Investigator Certification. Among other requirements, the certification ensures that the PI will maintain, electronically and/or in hard copy, the signed Authorization for each research ...

Recommended Content:

Privacy Board

Required Representations for Review Preparatory to Research

Form/Template
8/1/2012

Use this form if the researcher intends to conduct a review of PHI to prepare for a research protocol or for similar purposes preparatory to research (e.g., for recruitment or screening purposes) and agrees not to remove the PHI from DHA, the PI may submit this template to document the required representations, as outlined above, that are necessary ...

Recommended Content:

Privacy Board

Research Authorization Review

Form/Template
8/1/2012

Use this form if the researcher intends to obtain HIPAA Authorizations, also known as “Authorizations,” from research participants to comply with the HIPAA Privacy Rule, the PI must submit to the DHA Privacy Board a copy of the blank Authorization(s) to be used in the project and the completed Research Authorization Review. The DHA Privacy Board will ...

Recommended Content:

Privacy Board

Required Representations for Research on Decedents Information

Form/Template
8/1/2012

Use this form if the researcher intends to conduct research that is solely on the protected health information (PHI) of decedents, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and Department of Defense (DoD) Health Information Privacy ...

Recommended Content:

Privacy Board

Request for Mitochondrial DNA Sequence Report

Form/Template
2/1/2012

Use this form to request a copy of your mitochondrial DNA type to help recover family member remains.

Recommended Content:

DNA Identification Laboratory

CMS-1500 Health Insurance Claim Form

Form/Template
2/1/2012

Health Insurance Claim form for Medicare Professional Services.

Recommended Content:

Health Plan and Policy Billing Guidelines
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