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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.

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Family Reference Collection Form

Form/Template
6/22/2016

This form is used to establish a DNA reference specimen repository and database of information from kindred family members of unaccounted for/unidentified service members or other individuals needing to be identified. DNA will be extracted from a biological specimen or personal effect and used in identifying human remains.

Recommended Content:

DoD DNA Operations | DNA Identification Laboratory

Surgery Scheduling System (S3)

Form/Template
6/20/2016

PIA for the Surgery Scheduling System S3

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

DVEIVR PIA

Form/Template
6/15/2016

Privacy Impact Assessment (PIA) Summary for Defense and Veterans Eye Injury and Vision Registry (DVEIVR)

MDR PIA

Form/Template
6/15/2016

Privacy Impact Assessment (PIA) Summary for the Military Health System (MHS) Data Repository (MDR)

AFMES Form 25: Histology Request and Specimen Storage

Form/Template
6/1/2016

Use this form to obtain information/specimens needed for histology tissue processing and/or specimen storage.

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner

TRICARE Dispute Resubmission Form

Form/Template
5/26/2016

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

MDR Export Transmittal Form

Form/Template
5/25/2016

MDR Export Transmittal Form. This needs to be filled out if you are exporting more than 10,000 records.

Recommended Content:

MDR Functional Specifications

UFBPA UFADP Appendix August 2016: Migraine

Form/Template
5/6/2016

UF BPA and UF ADP Appendix for Migraine Agents-Triptans

UFBPA UFADP Appendix August 2016: Acne

Form/Template
5/6/2016

UF BPA and UF ADP Appendix for Acne Agents-Topical Acne and Rosacea Agents

UFBPA UFADP Appendix August 2016: Alcohol

Form/Template
5/6/2016

UF BPA and UF ADP Appendix for Alcohol Deterrents-Narcotic Antagonists

Data Exchange Service_DES

Form/Template
5/2/2016

PIA Summary for the Data Exchange Service (DES)

Form

Form/Template
5/2/2016

Privacy Impact Assessment Summary for the Clinical Enterprise Intelligence Program (CEIP)

Toxicology Submission Guidelines

Form/Template
4/4/2016

Guidelines for the collection and shipment of toxicology specimens

Recommended Content:

Forensic Toxicology

DHA Form 61, Privacy Threshold Analysis (PTA)

Form/Template
3/31/2016

The purpose of the PTA is to identify if a system contains personally identifiable information (PII); and determine whether a Privacy Impact Assessment (PIA) is required, whether a System of Records Notice (SORN) is required, and if any other privacy requirements apply to the information system.

Recommended Content:

Privacy Impact Assessments | Privacy and Civil Liberties

Report of Medical Assessment, DD Form 2697

Form/Template
3/30/2016

This form is used by the Medical Services to provide a comprehensive medical assessment for active and reserve component service members separating or retiring from active duty.

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

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