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Military Health System

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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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KARL STORZ Integrated Operating Room (i-OR) System with LiveData


This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the KARL STORZ Integrated Operating Room (i-OR) System with LiveData system.

Plan of Action and Milestone Template


This template is used to track plans of action and milestones regarding potential breaches.

Cosmetic Surgery Superbill 2014


Use this form to bill for cosmetic surgery.

Formal Appeal Request


Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-03) Complete this form when submitting a formal appeal for denied medical claims or denied pre-authorization requests by the DHA, Great Lakes.

Forensic DNA Specimen Analysis Request


Used to obtain information/specimens needed to evaluate and document forensic DNA testing.

General Data Request Template (DRT) Extractions (for all other DHA Systems)


The Data Request Template for General Extractions is required for a Data Sharing Agreement Application.

Data Request Template (DRT) - Access by Login (all DHA Systems)


The Data Request Template for Access by Login for all DHA Systems is required for a Data Sharing Agreement Application.

MHS IM-IT Submissions Form Instructions


Instructions for completing the MHS IM-IT Submissions Form. The form is used to submit an idea that fosters a change to an IM/IT capability, policy/process, or system.

DHA Small Vendor Business Profile List


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 other information necessary for potential contracting opportunities with DHA. The below information captures such information and is used only to assist within the identification process. Completing and submitting this form is voluntary. DHA does not guarantee that your company will be selected for, or awarded a contract to provide products or services.

Researcher Responsibilities


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 includes provisions related to any DOD biomedical research to comply with FDA regulations.

Collections Access Request


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

MHS NoPP Acknowledgement Form


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, 5263, 2163, 5923, 5963 (size: 2 inches x 4 inches).

Neuroimaging following TBI in non deployed setting


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, research and civilian sectors.

Cosmetic Surgery Superbill 2013


Use this form to bill for cosmetic surgery.

DCoE Concussion Management Algorithm Cards


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

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Last Updated: July 11, 2023
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