Back to Top Skip to main content

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.

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
9/15/2017

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
9/15/2017

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

PC TSMP Worksheet

Form/Template
8/1/2017

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

PC TSMP Worksheet Continuation Sheet

Form/Template
8/1/2017

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

DHA Privacy Office Standard Contract Language

Form/Template
7/6/2017

This Section addresses the Contractor’s requirements under The Privacy Act of 1974 (Privacy Act), The Freedom of Information Act (FOIA), and The Health Insurance Privacy and Accountability Act (HIPAA) as set forth in applicable statutes, implementing regulations and DoD issuances.

Recommended Content:

Privacy and Civil Liberties | DHA Privacy Contract Language

340b Verification Form

Form/Template
6/30/2017

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

Unsolicited Additional Discount Program Agreement

Form/Template
6/13/2017

TRICARE Retail Refund Program Unsolicited Additional Discount Program Bid. To be completed and submitted for new Unsolicited ADP Bids.

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).

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.

Sample WISDOM Agenda 5 Day

Form/Template
4/12/2017

Recommended Content:

M2 Functional Specifications | MDR, M2, ICDs Functional Support

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-02: Pre-Authorization Request

Form/Template
4/10/2017

Defense Health Agency - Great Lakes Worksheet (DAH-GL Worksheet-02) This worksheet is used to request pre-authorization for medical care for 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.

<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 19

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing: Download a PDF Reader or learn more about PDFs.