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Military Health System

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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 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.

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Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA)

Form/Template
6/5/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA).

DOD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DOD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.

Protected Health Information Management Tool (PHIMT)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Protected Health Information Management Tool (PHIMT) system.

DHA-GL Worksheet-01: Medical Eligibility Verification

Form/Template
4/10/2017

Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members

DHA-GL Worksheet-06: Surgical Pre-Authorization Request

Form/Template
4/10/2017

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.

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
4/6/2017

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

DSADHA Certification Data Disposition 20180611

Form/Template
1/30/2017

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.

DSA Change of Applicant/Recipient

Form/Template
1/30/2017

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.

DSA Change of Government Sponsor

Form/Template
1/30/2017

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.

U.S. Army Warrior Care and Transition Brand Questionnaire

Form/Template
1/23/2017

This brief questionnaire will help us determine how we brand the Army's Warrior Care Program. All responses are anonymous.

DMRTI EWSC Registration Form

Form/Template
12/29/2016

Student enrollment form to register in the DMRTI EWSC Course

Defense Health Agency Speaker Request Form

Form/Template
12/16/2016

Use this form to request a speaker from the Defense Health Agency. Try and submit your request as early as possible to allow our potential speakers time to coordinate their demanding schedules. 90 days of notice is a good rule of thumb, especially for events that require travel.

DD Form 2807-1: Report of Medical History

Form/Template
12/13/2016

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 condition(s) noted on the prescreening form (DD Form 2807-2).

C4 Welcome Letter

Form/Template
11/2/2016

Welcome Letter for the DMRTI C4 Course

MTF NCPDP NPI Request Form

Form/Template
9/9/2016

Use this form to request a new NCPDP/NPI Number

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Last Updated: July 19, 2022
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