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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.

Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DoD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.

Protected Health Information Management Tool (PHIMT)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Protected Health Information Management Tool (PHIMT) system.

Sample WISDOM Agenda 5 Day

Form/Template
4/12/2017

Recommended Content:

M2 Functional Specifications | MDR, M2, ICDs Functional Support

DHA-GL Worksheet-01: Medical Eligibility Verification

Form/Template
4/10/2017

Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members

DHA-GL Worksheet-06: Surgical Pre-Authorization Request

Form/Template
4/10/2017

Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-06) This form is used to request pre-authroization for surgical care from the DHA, Great Lakes.

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
4/6/2017

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

Data Sharing Agreement Application (DSAA)

Form/Template
3/6/2017

The Data Sharing Agreement Application (DSAA) is used when requesting data from systems that are owned and/or managed by DHA.

Recommended Content:

Submit a Data Sharing Application

Data Sharing Agreement (DSA) - Renewal Request

Form/Template
3/6/2017

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

Recommended Content:

Submit a Data Sharing Application

AFRSSIR Supply Order Request

Form/Template
2/21/2017

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

Recommended Content:

Armed Forces Repository of Specimen Samples for the Identification of Remains (AFRSSIR) | Specimen Collection Supplies Ordering Instructions

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

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

DSADHA Certification Data Disposition 20180611

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 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

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

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

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