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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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Data Sharing Agreement Application (DSAA)

Form/Template
10/25/2019

The Data Sharing Agreement Application (DSAA) is used when requesting data from systems that are owned and/or managed by DHA.

Recommended Content:

Submit a Data Sharing Application

Data Sharing Agreement (DSA) - Renewal Request Template 2019.10.28

Form/Template
10/25/2019

The Data Sharing Agreement Renewal Request template is used when requesting the renewal of an executed DSA.

Recommended Content:

Submit a Data Sharing Application

Request for DoD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary

Form/Template
10/4/2019

Please attach MTF P&T Committee comments & meeting minutes, an explanation of the rationale for the request, copies of supporting clinical evidence, and anything else that needs to be considered by the DoD P&T Committee.

Recommended Content:

TRICARE Formulary

MHS GENESIS / Defense Healthcare Management System Modernization Electronic Health Record (DHMSM EHR)

Form/Template
9/30/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the MHS GENESIS / Defense Healthcare Management System Modernization Electronic Health Record (DHMSM EHR)

Recommended Content:

MHS GENESIS | Federal Electronic Health Record Modernization (FEHRM) Program Office

Dental Imaging Collaborative Environment (DICE)

Form/Template
9/24/2019

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the Dental Imaging Collaborative Environment (DICE) system.

TRICARE E-Commerce (TMA ECS)

Form/Template
9/24/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the TRICARE E-Commerce (TMA ECS) system.

Spectacle Request and Transmission System (SRTS)

Form/Template
9/20/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) describes the Spectacle Request and Transmission System (SRTS). The SRTS is a Government developed clinic and laboratory web-based application that serves as the sole electronic system for ordering and tracking military eyewear.

DHA-GL Worksheet 07a: DVA/DoD MOA Continued Stay for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL: How to Submit Request for Durable Medical Equipment Pre- Authorization

Form/Template
8/29/2019

This process guides references how to submit Request for Durable Medical Equipment for Pre- Authorization of Inpatient or Outpatient Medical Care at a VA Facility under DVA/DoD Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

DHA-GL: How to Submit Discharge Summary notification

Form/Template
8/29/2019

This process guides references how to submit Discharge Summary notification from Inpatient or Outpatient Medical Care at a VA Facility under DVA/DoD Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

DHA-GL Worksheet 08: DVA/DoD MOA SCI-TBI-Blind DME Request Worksheet

Form/Template
8/29/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab STAR Program

Form/Template
8/29/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

CIS Essentris PIA

Form/Template
8/19/2019

This Privacy Impact Assessment (PIA) documents compliances for CIS-Essentris

Steps to take for Potentially Compromised Vaccine Event

Form/Template
8/12/2019

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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