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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 five 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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We found 506 items

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Form/Template
Jun 18, 2024

Assistance Reporting Tool 2024

.PDF | 673.60 KB

Privacy impact assessment for the Assistance Reporting Tool is a secure web-based system that captures authorizations and feedback on TRICARE related benefits. Customer service personnel use ART to document beneficiary questions and concerns related to TRICARE and how those issues are resolved.

Form/Template
Jun 18, 2024

Enterprise Patient Queuing and Notification System

.PDF | 564.01 KB

Privacy impact assessment for the Enterprise Patient Queuing Notification System automates patient check-in during visits to Military Treatment Facilities and clinics.

Form/Template
Jun 13, 2024

Samsung Electronics Digital Radiography System G Series 2 x

.PDF | 740.29 KB

Privacy impact assessment for the Samsung Electronics Digital Radiography System G Series 2.x is a radiographic system used in hospitals, clinics, and medical practices. The G Series is comprised of multiple platforms utilizing the S-Station 2.x software package.

Form/Template
Jun 13, 2024

Nuclear Medicine Information System Biodose

.PDF | 747.26 KB

Privacy impact assessment for the Nuclear Medicine Information System Biodose. NMIS is an application hosted on a Virtual Machine Windows 2019 server. NMIS is only used by Radiology, particularly in the Nuclear Medicine Division, Radiation Safety, and National Intrepid Center of Excellence Nuclear Medicine.

Form/Template
Jun 13, 2024

DHA E-Commerce System

.PDF | 740.88 KB

Privacy impact assessment for the The Defense Health Agency E-Commerce System provides an integrated contract management suite and financial management applications supporting private sector care.

Form/Template
Jun 13, 2024

354th MDG Eielson AFB MEDCOI

.PDF | 733.68 KB

Privacy impact assessment for the 354th Medical Group Eielson AFB Medical Community of Interest enclave will provide core services to the medical center's enterprise to include collections of storage arrays, networking infrastructure, backup and recovery devices, virtual server infrastructure, physical servers, file and print servers, local ...

Form/Template
Jun 13, 2024

DoD North Chicago Enterprise Service Bus ESB

.PDF | 653.55 KB

Privacy impact assessment for the Department of Defense (DoD) North Chicago Enterprise Service Bus (ESB) application provides synchronization and/or mapping to support message translation between patient registration and/or patient lookup and laboratory, radiology, and outpatient medication orders entered in the Composite Health Care System (CHCS) or ...

Form/Template
Jun 13, 2024

DOD Drug Demand Reduction Program Med COI

.PDF | 731.07 KB

Privacy impact assessment for the DOD-Drug Demand Reduction Program-MedCOI enclave is not part of an MTF, but consists of hardware, software, and telecommunications architecture to provide forensic drug testing to DOD commands located globally.

Form/Template
Jun 13, 2024

Defense Occupational and Environmental Health Readiness System Industrial Hygiene DOEHRS IH

.PDF | 684.61 KB

Privacy impact assessment for the Defense Occupational and Environmental Health Readiness System -Industrial Hygiene (DOEHRS-IH) is a data collecting, reporting and analytical system that allows the Department of Defense (DoD) to manage occupational and environmental health (OEH) risk data and actively track biological, chemical, and physical health ...

Form/Template
Jun 13, 2024

Data Exchange Service GovCloud

.PDF | 764.10 KB

Privacy impact assessment for The purpose of Data Exchange Service GovCloud is to offer a solution for health information exchange across organizations and to provide legacy health record data to systems that support clinical decisions and benefit adjudication.

Form/Template
Jun 4, 2024

Philips IntelliVue Information Center iX C032697 AA

.PDF | 581.01 KB

Privacy impact assessment for the Philips Patient Information Center iX (PICiX) software application is to Receive, aggregate, process, distribute, and display physiologic waves, parameters, alarms and events at locations other than at the patient, for multiple patients.

Form/Template
Jun 4, 2024

Reynolds AHC Ft Sill MEDCOI

.PDF | 742.22 KB

Privacy impact assessment for Reynolds AHC -Ft Sill_MEDCOI enclave architecture consists of hardware, software, and telecommunications systems. The enclave includes user interfaces such as workstations and laptops and hosts office automation as well as medical systems and applications.

Form/Template
Jun 4, 2024

Protected Health Information Management Tool PHIMT

.PDF | 760.91 KB

Privacy impact assessment for the Protected Health Information Management Tool (PHIMT) provides the Military Health System (MHS) with a web-based application that simplifies and automates many of the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule.

Form/Template
Jun 4, 2024

Quidel Sofia Analyzers Version 2X AI

.PDF | 651.70 KB

Privacy impact assessment for the Quidel Sofia Analyzers (AI) (Sofia Analyzers), an enterprise-wide information system, is a professional use laboratory small bench top analyzer using fluorescence detection to identify infectious diseases like Coronavirus Disease (COVID-19).

Form/Template
Jun 4, 2024

42nd MDG Maxwell AFB MEDCOI

.PDF | 735.55 KB

Privacy impact assessment for the 42nd MDG Maxwell AFB_MEDCOI enclave architecture consists of hardware, software, and telecommunications systems. The enclave includes user interfaces such as workstations and laptops and hosts office automation as well as medical systems and applications

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