AGFA NX Family of Systems (CR/DR) vNX27_A&I
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.
Looking for an official Defense Health Agency Form?
- Please visit the DHA Forms Management page on Inside DHA. CAC authentication is required.
- If you have questions, please send an email to the DHA Forms Management Office.
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Recent Forms & Templates
Image Management Systems Dental Imaging and Infrastructure
NeoLight Phoenix ICON v1.x_A&I
Reynolds AHC - Ft Sill MEDCOI
Vance MDG MEDCOI
Bio-Rad Variant II Hemoglobin Testing System Series v5.x A&I
Nihon Kohden Family of EEG Neurology & Sleep Devices V.12.x_A&A
Medtronic EndoFlip 300 System Series v3.x A&I
MHS GENESIS Electronic Health Record
Pharmacy Outpatient Automation Solution - iA
Popular Forms & Templates
Neurobehavioral Symptom Inventory Form
DHA-GL Worksheet 02: Pre-Authorization Request
DHA-GL Worksheet 01: Medical Eligibility Verification
Medical Readiness Decision Support System (MRDSS)
Patient Global Impression Change Scale
MHS Service Help Desk
Financial Management Information System
Siemens Somatom Somaris VB10X_A&I
MHS GENESIS Electronic Health Record
Limited Duty Sailor and Marine Readiness Tracker MHS Application Access Gateways
Form/Template
Oct. 4, 2017
CS SCE Access Instructions
.DOCX |
33.71 KB
Instructions for completing the necessary forms to apply for a MDR user's account
Form/Template
June 5, 2017
Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA)
.PDF |
181.26 KB
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA).
Form/Template
April 10, 2017
DHA-GL Worksheet-01: Medical Eligibility Verification
.PDF |
133.79 KB
Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members
Form/Template
April 10, 2017
DHA-GL Worksheet-06: Surgical Pre-Authorization Request
.PDF |
137.36 KB
Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-06) This form is used to request pre-authroization for surgical care from the DHA, Great Lakes.
Form/Template
April 6, 2017
TRICARE Retail Pharmacy Program Questionnaire
.PDF |
206.22 KB
Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.
Form/Template
Jan. 30, 2017
DSADHA Certification Data Disposition 20180611
.PDF |
322.87 KB
This template is for the sole purpose of certifying that data used in connection with a Data Sharing Agreement (DSA) that was executed with the DHA Privacy and Civil Liberties Office (Privacy Office) has been appropriately disposed of in a timely manner.
Form/Template
Jan. 30, 2017
DSA Change of Applicant/Recipient
.PDF |
89.82 KB
This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Applicant / Recipient listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Applicant / Recipient.
Form/Template
Jan. 30, 2017
DSA Change of Government Sponsor
.PDF |
126.07 KB
This template shall be used to notify the DHA Privacy and Civil Liberties Office (Privacy Office) that the Government Sponsor listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Government Sponsor.
Form/Template
Dec. 29, 2016
DMRTI EWSC Registration Form
.DOC |
43.50 KB
Student enrollment form to register in the DMRTI EWSC Course
Form/Template
Dec. 13, 2016
Report of Medical History
The primary collection of this information is from individuals seeking to join the armed forces. The information collected on this form is used to assist DoD physicians in making determinations as to acceptability of applicants for military service and verifies disqualifying medical conditions noted on the prescreening form (DD 2807-2). An additional ...
Form/Template
Nov. 2, 2016
C4 Welcome Letter
.PDF |
156.13 KB
Welcome Letter for the DMRTI C4 Course
Form/Template
Sept. 9, 2016
MTF NCPDP NPI Request Form
.PDF |
67.35 KB
Use this form to request a new NCPDP/NPI Number
Form/Template
Sept. 9, 2016
MTF ePharmacy NCPDP NPI Request Form
.PDF |
94.41 KB
Use this form to requests a new ePharmacy NCPDP/NPI number
Form/Template
Sept. 1, 2016
DD Form 2569
Your information is collected to allow recovery from third parties for medical care provided to you in a military treatment facility.
Form/Template
July 7, 2016
MTF ePharmacy Demographic Change Request Form
.PDF |
67.33 KB
For assistance completing this form or any other related information, e-mail the DHA PASS general mailbox dha.jbsa.pharmacy.mbx.pass@mail.mil or call the DHA PASS at 1-866-275-4732 / (210) 536-6650, press option 1.
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