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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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MTF ePharmacy Demographic Change Request Form

Form/Template
7/7/2016

For assistance completing this form or any other related information, e-mail the DHA PASS general mailbox dha.jbsa.pharmacy.mbx.pass@mail.mil or call the DHA PASS at 1-866-275-4732 / (210) 536-6650, press option 1.

TRICARE Webinar Feedback

Form/Template
6/27/2016

Use this form to submit feedback about the webinar on June 22, 2016 titled, "An Overview of the TRICARE Retail Refunds Program Dispute Resolution Process."

Military Health System Data Repository

Form/Template
6/23/2016

Military Health System (MHS) Data Repository (MDR) PIA

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

Defense and Veterans Eye Injury and Vision Registry

Form/Template
6/22/2016

PIA for the Defense and Veterans Eye Injury and Vision Registry (DVEIVR)

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

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.

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

MDR PIA

Form/Template
6/15/2016

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

DVEIVR PIA

Form/Template
6/15/2016

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

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: Alcohol

Form/Template
5/6/2016

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

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

Form

Form/Template
5/2/2016

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

Data Exchange Service_DES

Form/Template
5/2/2016

PIA Summary for the Data Exchange Service (DES)

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

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