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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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EACE Data Request Form

Form/Template
11/20/2019

Form for users to fill out to request information/data from EACE

DHA-GL Worksheet 41: DOD/VA MOA Inpatient-Outpatient Continued Stay Review

Form/Template
11/20/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization VAMC Richmond Only

Form/Template
11/14/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet : Discharge Summary

Form/Template
11/14/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

Request for DOD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary

Form/Template
10/4/2019

Please attach MTF P&T Committee comments & meeting minutes, an explanation of the rationale for the request, copies of supporting clinical evidence, and anything else that needs to be considered by the DOD P&T Committee.

MHS GENESIS / Defense Healthcare Management System Modernization Electronic Health Record (DHMSM EHR)

Form/Template
9/30/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the MHS GENESIS / Defense Healthcare Management System Modernization Electronic Health Record (DHMSM EHR)

Dental Imaging Collaborative Environment (DICE)

Form/Template
9/24/2019

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the Dental Imaging Collaborative Environment (DICE) system.

TRICARE E-Commerce (TMA ECS)

Form/Template
9/24/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the TRICARE E-Commerce (TMA ECS) system.

Spectacle Request and Transmission System (SRTS)

Form/Template
9/20/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) describes the Spectacle Request and Transmission System (SRTS). The SRTS is a Government developed clinic and laboratory web-based application that serves as the sole electronic system for ordering and tracking military eyewear.

DHA-GL Worksheet 07a: DOD/VA MOA Continued Stay for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 08: DOD/VA MOA SCI-TBI-Blind DME Request Worksheet

Form/Template
8/29/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab STAR Program

Form/Template
8/29/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL: How to Submit Discharge Summary notification

Form/Template
8/29/2019

This process guides references how to submit Discharge Summary notification from Inpatient or Outpatient Medical Care at a VA Facility under DOD/VA Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

DHA-GL: How to Submit Request for Durable Medical Equipment Pre-Authorization

Form/Template
8/29/2019

This process guides references how to submit Request for Durable Medical Equipment for Pre- Authorization of Inpatient or Outpatient Medical Care at a VA Facility under DOD/VA Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

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Last Updated: July 19, 2022
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