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Forms & Templates

On this page, you will find various forms that Defense Health Agency 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.

Showing results 1 - 15 Page 1 of 19

Temp Log F

Form/Template
9/20/2016

Recommended Content:

Vaccine Storage and Handling

Surgical Scheduling System

Form/Template
9/16/2016

PIA summary for Surgical Scheduling System.

Recommended Content:

Privacy and Civil Liberties, Privacy Impact Assessments

DHA Privacy Office Standard Contract Language

Form/Template
9/16/2016

Recommended Content:

Privacy and Civil Liberties, DHA Privacy Contract Language

MTF ePharmacy NCPDP NPI Request Form

Form/Template
9/9/2016

MTF NCPDP NPI Request Form

Form/Template
9/9/2016

MTF Request epharmacy ncpdp npi form

Form/Template
9/7/2016

CD-MART Request Form

Form/Template
8/23/2016

This form is used to assist providers in the identification of patients who have received prescriptions for controlled substances over a given period of time and provide them with an automated process to analyze the data.

Recommended Content:

PC TSMP Worksheet Continuation Sheet

Form/Template
8/18/2016

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling, Potential Vaccine Compromise Reporting

PC TSMP Worksheet

Form/Template
8/18/2016

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling, Potential Vaccine Compromise Reporting

Zeiss FORUM

Form/Template
8/12/2016

Zeiss FORUM PIA summary

Recommended Content:

Privacy and Civil Liberties, Privacy Impact Assessments

Vendor Information Form

Form/Template
7/27/2016

The Vendor Information Form provides a standard way to collect your ideas, problem statements, and/or proposed solution sets for defense health IT.

Recommended Content:

Technology, Health IT Research and Innovation, Health IT Research and Innovation, Health IT Research and Innovation, Health IT Research and Innovation

Department of Defense Consolidated Cancer Registry (CCR)

Form/Template
7/21/2016

Department of Defense Consolidated Cancer Registry (CCR) System PIA summary

Recommended Content:

Privacy and Civil Liberties, Privacy Impact Assessments

Request for Deployment (P-MART) or Warriors in Transition (WTU-MART)

Form/Template
7/18/2016

Use this form to request sensitive data in support of deployments (P-MART) or warriors in transition (WTU-MART).

Recommended Content:

PDTS Data Report Request Form

Form/Template
7/18/2016

The PDTS reports function is constantly evolving and as we continue to find new applications for the data collected by PDTS, the reports function will be modified to meet those demands.

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."

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Showing results 1 - 15 Page 1 of 19

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

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