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New FDA Guidance for Long-standing Deferral; HIV Changes
The Food and Drug Administration issued new guidance on blood donations, removing some long-standing deferrals. In addition to this, the FDA is also considering moving towards an individualized risk-based approach when deciding donor eligibility. These changes are related to HIV medications and those at risk for contracting HIV.
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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.
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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.
Used to obtain information/specimens needed to evaluate and document forensic DNA testing.
The Data Request Template for Access by Login for all DHA Systems is required for a Data Sharing Agreement Application.
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The Data Request Template for General Extractions is required for a Data Sharing Agreement Application.
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.
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.
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.
Form used to request access to the collections at the National Museum of Health and Medicine.
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).
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.
Use this form to bill for cosmetic surgery.
Combat Medic/Corpsman Algorithm Card to diagnose a concussion in a deployed setting
Use this form if a Research Authorization Review template and an Authorization are approved by the DHA Privacy Board, a Principal Investigator (PI) will be required to sign a Principal Investigator Certification. Among other requirements, the certification ensures that the PI will maintain, electronically and/or in hard copy, the signed Authorization for each research participant whose PHI is used or disclosed in the project, and will provide any and/or all of the signed Authorizations to DHA immediately upon request.
Use this form if the researcher intends to conduct a review of PHI to prepare for a research protocol or for similar purposes preparatory to research (e.g., for recruitment or screening purposes) and agrees not to remove the PHI from DHA, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and DOD 6025.18-R.
Use this form if the researcher intends to obtain HIPAA Authorizations, also known as “Authorizations,” from research participants to comply with the HIPAA Privacy Rule, the PI must submit to the DHA Privacy Board a copy of the blank Authorization(s) to be used in the project and the completed Research Authorization Review. The DHA Privacy Board will conduct a review to determine that all core elements and required statements are provided in the Authorization(s) as required by the HIPAA Privacy Rule and DOD 6025.18-R.
The appearance of hyperlinks does not constitute endorsement by the Department of Defense of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website.