Office of Assistant Secretary for Health Affairs


Federal Forms

OMB NumberTitle
0720-0072 Health Related Behaviors Survey
0720-0071 Centralized Credentials and Quality Assurance System
0720-0070 Childbirth and Breastfeeding Demonstration Survey
0720-0069 DoD COVID-19 Vaccine Questionnaire
0720-0068 COVID-19 Vaccine Screening and Immunization Documentation
0720-0067 Personnel Accountability and Assessment for a Public Health Emergency
0720-0066 Continued Health Care Benefit Program (CHCBP) Application
0720-0065 Assessment of Real Warriors Campaign’s Impact on Negative Perceptions about Mental Health Conditions and Treatment and Awareness of Resources
0720-0064 MHS GENESIS Patient Registration Module & Patient Portal
0720-0063 Preservation of the Force and Family (POTFF) Spiritual Fitness Metrics
0720-0062 Comparing Hospital Hand Hygiene in Liberia: Soap, Alcohol, and Hypochlorite
0720-0061 TRICARE Select Enrollment, Disenrollment, and Change Form
0720-0060 Assistance Reporting Tool (ART)
0720-0059 Patient Centered Medical Home (PCMH) Staff Satisfaction Survey
0720-0058 Department of Defense Suicide Event Report (DoDSer)
0720-0057 Enterprise Blood Management System (EBMS)
0720-0056 Screening and Monitoring of DoD Personnel Deployed to Ebola Outbreak Areas
0720-0055 Third Party Collection Program (Insurance Information)
0720-0054 ACAM2000® Myopericarditis Registry
0720-0053 Active Duty Dental Program Claim Form
0720-0052 Military Nurse Recruitment Surveys
0720-0050 Retired Troops to Nurse Teachers Survey
0720-0049 TRICARE Young Adult Application
0720-0048 Award Fee Provider Survey
0720-0047 An Outcome Evaluation of the SOS Signs of Suicide Prevention Program
0720-0046 Women, Infants and Children Overseas Participant Satisfaction Survey
0720-0045 TRICARE Dual Eligible Fiscal Intermediary Contract Provider Satisfaction Survey
0720-0044 Certification of Non-Contributory TRICARE Supplement Insurance
0720-0043 Retention of Behavior Health Providers Survey
0720-0042 Researcher Responsibilities Acknowledgement
0720-0041 Defense Medical Human Resources System Internet (DMHRSi)
0720-0040 Facilitating Provider Acceptance of TRICARE Standard
0720-0039 TRICARE Satisfaction Survey of Network Providers
0720-0038 Public Perception of the Military Health System (Focus Groups)
0720-0035 TRICARE Dental Program (TDP) Claim Form
0720-0034 Department of Defense (DoD) Patient Safety Culture Survey
0720-0032 TRICARE Retail Refunds Request User Account Access
0720-0031 TRICARE: Select Survey of Civilian Providers
0720-0030 Women, Infants, and Children Overseas - Eligibility Determination
0720-0029 Prospective Studies of US Military Forces: The Millennium Cohort Study
0720-0028 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
0720-0027 Health Evaluation Assessment Review (HEAR 2.X)
0720-0025 TRICARE for Life Beneficiary Information Update Form
0720-0024 Survey of Prescribers in Military Treatment Facilities and TRICARE Contracts
0720-0023 Pharmacy Redesign Pilot Program
0720-0022 DoD Active Duty/Reserve Forces Dental Examination
0720-0021 Armed Forces Health Professions Loan Repayment Program Loan Information and Verification Form
0720-0020 Application for TRICARE-Provider Status: Corporate Services Provider
0720-0018 TRICARE Senior Prime Enrollment Application Form
0720-0017 Diagnosis Related Groups (DRG) Reimbursement (Two Parts)
0720-0016 Women's Health Care in the Field Environment
0720-0015 TRICARE Retiree Dental Program Enrollment Application
0720-0013 Health Insurance Claims Form, UB-04 CMS 1450
0720-0012 Department of Defense Khamisiyah Survey
0720-0011 Epidemiologic Studies of Morbidity Among Gulf War Veterans: A Search for Etiologic Agents and Risk Factors, Seabee Health Study (Study 5)
0720-0010 Epidemiologic Studies of Morbidity Among Gulf War Veterans: A Search for Etiologic Agents and Risk Factors
0720-0009 Provider Certification Requirements-Corporate Services Provider Class; Occupational Therapists
0720-0008 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change
0720-0006 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
0720-0005 Professional Qualifications, Medical and Peer Reviewers
0720-0003 Statement of Personal Injury: Possible Third Party Liability
0720-0001 Health Insurance Claim Form

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