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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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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

DHA PIA Desk Reference Guide

Form/Template
3/21/2016

The DHA PIA Guide addresses the common issues encountered during the completion of a PIA. This PIA Guide enhances the assessment process and helps the DHA Privacy and Civil Liberties Office efficiently conduct a PIA review to completion.

Recommended Content:

Privacy Impact Assessments

FCC Request Form

Form/Template
3/9/2016

Student nomination form for the FCC/PRA Basic Operations Course

EPRC Course for Executives/Commanders: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Operator/Responder: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Clinicians: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Clinicians: Attestation Statment

Form/Template
3/8/2016

Must be completed and signed to get a certificate.

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

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