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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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MDR Special Justification Form

Form/Template
4/1/2020

Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.

DD Form 3111: Routine Immunization Screening Form: Adults

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for adults.

DD Form 3110: Routine Immunization Screening Form: Pediatric

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for children and teens.

Smallpox Vaccine Screening Form

Form/Template
3/2/2020

Each potential recipient of smallpox vaccine must complete this official screening form and it must be signed by a licensed health care provider prior to vaccination.

AFRSSIR Supply Order Request

Form/Template
2/12/2020

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

DMRTI JOP Student Nomination_JAN20

Form/Template
1/22/2020

Student nomination form for both JMOCs and JMPT.

Form 543

Form/Template
1/2/2020

DMRTI JOP Student Nomination

Form/Template
12/11/2019

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

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.

EACE Data Request Form

Form/Template
11/20/2019

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

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.

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Last Updated: July 11, 2023
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