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This form should be completed and signed by the prescriber to request prior authorization to use a brand name drug instead of a generic equivalent.
This form is for institutional providers to apply for enrollment in the Medicare program or make a change in their enrollment information.
This form is a tool that can be used when a collaborating investigator is not part of an institution with a federal assurance.
Use this form to grant permission to the Armed Forces Medical Examiner System to retain organs for an extended examination to determine cause of death.
This form should be used when an institution will be engaged in human subject research and will use an Institutional Review Board (IRB) that is not organizationally or legally part of the institution.
Use this worksheet when referring a service member under the Supplemental Health Care Program.
Designed to help investigative agencies to better understand the circumstances and factors contributing to unexplained infant (less than 1 year old) deaths. View more information about the form at: http://www.cdc.gov/sids/SUIDRF.htm
This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DOD policies and requirements since the DHHS FWA does not identify DOD requirements.
The Office of the Under Secretary of Defense for Personnel and Readiness requires that all research investigators (principal investigators as well as associate investigators) engaged in research with one of its institutions explicitly acknowledge and accept responsibility for protecting the rights and welfare of human research subjects as stated therein.
Used to record disposition of remains desired by the person authorized to direct disposition of remains (PADD).
Privacy Impact Assessment (PIA) for the Theater Medical Data Store (TMDS).
To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
This form is used to record DU Bioassay/Fragment Testing and Results Information
This form is to provide the patient with a means to request a restriction on the use and disclosure of his/her protected health information.
This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.
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