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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 Online (TOL)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the TRICARE Online (TOL) system.

International SOS (Intl.SOS) Case Management and Authorization System (TriCase)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the International SOS (Intl.SOS) Case Management and Authorization System (TriCase) system.

Military Health System (MHS) Management Analysis Reporting Tool (MART) (M2)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Military Health System (MHS) Management Analysis Reporting Tool (MART) (M2) system.

DoD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DoD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.

Referral Information Tracking Application (RITA)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Referral Information Tracking Application (RITA) system.

Personnel Security Branch (PSB) Case Management (CM)

Form/Template
7/29/2014

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Personnel Security Branch (PSB) Case Management (CM) 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.

Recommended Content:

Breaches of PII and PHI

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.

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.

Recommended Content:

Submit a Data Sharing Application

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.

Recommended Content:

Submit a Data Sharing 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.

Recommended Content:

Access, Cost, Quality, and Safety | Technology

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.

Recommended Content:

Small Business Programs | Small Business Programs

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.

Recommended Content:

Research and Innovation
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