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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.

Data Sharing Agreement Extension Request

Form/Template
1/30/2017

This template is used to request a 30 day extension in order to continue to use the data in accordance to the executed Data Sharing Agreement (DSA).

Recommended Content:

Submit a Data Sharing Application

Data Sharing Agreement (DSA) - Modification Request

Form/Template
1/30/2017

The Data Sharing Agreement Modification Request template is used when requesting the modification of an executed DSA.

Recommended Content:

Submit a Data Sharing Application

DSA Certification of Data Disposition

Form/Template
1/30/2017

This template is for the sole purpose of certifying that data used in connection with a Data Sharing Agreement (DSA) that was executed with the DHA Privacy and Civil Liberties Office (Privacy Office) has been appropriately disposed of in a timely manner.

Recommended Content:

Submit a Data Sharing Application

DSA Change of Applicant/Recipient

Form/Template
1/30/2017

This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Applicant / Recipient listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Applicant / Recipient.

Recommended Content:

Submit a Data Sharing Application

DSA Change of Government Sponsor

Form/Template
1/30/2017

This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Government Sponsor listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Government Sponsor.

Recommended Content:

Submit a Data Sharing Application

System Security Verification (SSV)

Form/Template
1/30/2017

The System Security Verification (SSV) template is used when data obtained through a DSAA will be stored, transmitted, processed, or otherwise maintained on an information system that has not been granted a Department of Defense (DoD) Authorization to Operate (ATO) or an Interim Authorization to Operate (IATO).

Recommended Content:

Submit a Data Sharing Application

PDTS Data Report Request Form

Form/Template
1/24/2017

The PDTS reports function is constantly evolving and as we continue to find new applications for the data collected by PDTS, the reports function will be modified to meet those demands.

DMRTI EWSC Registration Form

Form/Template
12/29/2016

Student enrollment form to register in the DMRTI EWSC Course

Defense Health Agency Speaker Request Form

Form/Template
12/16/2016

Use this form to request a speaker from the Defense Health Agency. Try and submit your request as early as possible to allow our potential speakers time to coordinate their demanding schedules. 90 days of notice is a good rule of thumb, especially for events that require travel.

CD-MART Request Form

Form/Template
12/7/2016

This form is used to assist providers in the identification of patients who have received prescriptions for controlled substances over a given period of time and provide them with an automated process to analyze the data.

Request for Deployment (P-MART) or Warriors in Transition (WTU-MART)

Form/Template
12/7/2016

Use this form to request sensitive data in support of deployments (P-MART) or warriors in transition (WTU-MART).

C4 Welcome Letter

Form/Template
11/2/2016

Welcome Letter for the DMRTI C4 Course

Temp Log F

Form/Template
9/20/2016

Monitoring the temperature of your vaccine storage unit is required at least twice a day, and should be logged using this form.

Recommended Content:

Vaccine Storage and Handling

Surgical Scheduling System

Form/Template
9/16/2016

PIA summary for Surgical Scheduling System.

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

MTF ePharmacy NCPDP NPI Request Form

Form/Template
9/9/2016

Use this form to requests a new ePharmacy NCPDP/NPI number

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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