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

Form/Template
2/28/2018

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.

Recommended Content:

TRICARE Formulary

UF BCF ECF OTC Request Form Feb 2018

Form/Template
2/26/2018

MTF Drug Request Review Form

PDTS Data Report Request Form

Form/Template
2/13/2018

The PDTS reports function is constantly evolving and as we continue to find new applications for the data collected by PDTS, the reports function will be modified to meet those demands.

Program Integrity Report Request Form

Form/Template
2/13/2018

This form is designed to accommodate requests for patient, drug, provider, and pharmacy profiles. If you need assistance completing this form please call the number shown above. The PASS cannot act on any report request until the form has been approved and the requestor has agreed with the method of extract and the structure of the report.

PDTS Report Request Form

Form/Template
2/13/2018

This form is used to assist providers in the identification of patients who have received prescriptions for controlled substances over a given period of time and provide them with an automated process to analyze the data.

Request for Deployment (P-MART) or Warriors in Transition (WTU-MART)

Form/Template
2/13/2018

Use this form to request sensitive data in support of deployments (P-MART) or warriors in transition (WTU-MART).

Smallpox Vaccine Screening Form

Form/Template
2/8/2018

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.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Storage Unit Sticker Template

Form/Template
2/1/2018

Some resources you can use to protect your vaccine storage unit and warn staff to not turn off power to the unit.

Recommended Content:

Vaccine Storage and Handling

TRICARE Retail Refund Appendix A Change Request Form

Form/Template
1/12/2018

Use this form to add/delete/transfer or make changes to your current Appendix A

Request for Autopsy Report and Supplemental Information

Form/Template
1/8/2018

Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.

Recommended Content:

Office of the Armed Forces Medical Examiner

JMOC or JMPT Nomination Form

Form/Template
12/29/2017

JMOC - JMPT Nomination Form

Amputation Care ECHO Facilitation Scorecard

Form/Template
11/22/2017

Use this form to score the facilitator.

Recommended Content:

Clinical Affairs

Patient Queuing and Notification System (PQNS)

Form/Template
11/15/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes Patient Queuing and Notification System (PQNS) system.

Coagulation Clinic (CoagClinic)

Form/Template
11/15/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Coagulation Clinic (CoagClinic) system.

Account Authorization Request Form

Form/Template
11/7/2017

Fillable form for access requests to MDR data.

Recommended Content:

MDR, M2, ICDs Functional Support | MDR Functional Specifications
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