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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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Delta Dental Federal Government Programs Information System (DDFGP-IS)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Delta Dental Federal Government Programs Information System (DDFGP-IS) system.

Defense Medical Human Resources System - Internet (DMHRSi)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Defense Medical Human Resources System - Internet (DMHRSi) system.

Designated Provider Health Care Delivery System (DPHCDS)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Designated Provider Health Care Delivery System (DPHCDS) system.

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

Form/Template
7/29/2014

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

United Concordia Companies Inc. (UCCI) Active Duty Dental Program (ADDP)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the United Concordia Companies Inc. (UCCI) Active Duty Dental Program (ADDP) system.

Plan of Action and Milestone Template

Form/Template
6/6/2014

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

Cosmetic Surgery Superbill 2014

Form/Template
6/1/2014

Use this form to bill for cosmetic surgery.

Formal Appeal Request

Form/Template
6/1/2014

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

Form/Template
5/19/2014

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

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

Form/Template
4/30/2014

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

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

Form/Template
4/30/2014

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

MHS IM-IT Submissions Form Instructions

Form/Template
4/16/2014

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

Form/Template
4/8/2014

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

Form/Template
2/27/2014

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/Template
12/1/2013

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

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Last Updated: July 19, 2022
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