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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.
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Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.
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Liberties Office (Privacy Office) that the Applicant / Recipient listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Applicant / Recipient.
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.
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Liberties Office (Privacy Office) that the Government Sponsor listed in an executed Data Sharing Agreement (DSA) has been replaced by a new Government Sponsor.
This brief questionnaire will help us determine how we brand the Army's Warrior Care Program. All responses are anonymous.
Student enrollment form to register in the DMRTI EWSC Course
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.
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).
Welcome Letter for the DMRTI C4 Course
Use this form to requests a new ePharmacy NCPDP/NPI number
Use this form to request a new NCPDP/NPI Number
Your information is collected to allow recovery from third parties for medical care provided to you in a military treatment facility.
The Vendor Information Form provides a standard way to collect your ideas, problem statements, and/or proposed solution sets for defense health IT.
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.
Use this form to submit feedback about the webinar on June 22, 2016 titled, "An Overview of the TRICARE Retail Refunds Program Dispute Resolution Process."
The appearance of hyperlinks does not constitute endorsement by the Department of Defense of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website.
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