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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.

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CMS-1500 Health Insurance Claim Form

Form/Template
2/1/2012

Health Insurance Claim form for Medicare Professional Services.

Recommended Content:

Health Plan and Policy Billing Guidelines

Brand over Generic Prior Authorization Form

Form/Template
8/10/2011

This form should be completed and signed by the prescriber to request prior authorization to use a brand name drug instead of a generic equivalent.

Medicare Enrollment Application, CMS-855A

Form/Template
7/1/2011

This form is for institutional providers to apply for enrollment in the Medicare program or make a change in their enrollment information.

Individual Investigator Agreement

Form/Template
3/29/2011

This form is a tool that can be used when a collaborating investigator is not part of an institution with a federal assurance.

Recommended Content:

Research Regulatory Oversight Office

Disposition of Organs Retained for Extended Examination

Form/Template
3/8/2011

Use this form to grant permission to the Armed Forces Medical Examiner System to retain organs for an extended examination to determine cause of death.

Recommended Content:

Office of the Armed Forces Medical Examiner

Institutional Agreement for IRB Review

Form/Template
8/30/2010

This form should be used when an institution will be engaged in human subject research and will use an Institutional Review Board (IRB) that is not organizationally or legally part of the institution.

Recommended Content:

Research Regulatory Oversight Office

Supplemental Health Care Program Worksheet

Form/Template
4/16/2010

Use this worksheet when referring a service member under the Supplemental Health Care Program.

Recommended Content:

Supplemental Health Care Program

Sudden Unexplained Infant Death Investigation Reporting Form

Form/Template
2/1/2010

Designed to help investigative agencies to better understand the circumstances and factors contributing to unexplained infant (less than 1 year old) deaths. View more information about the form at: http://www.cdc.gov/sids/SUIDRF.htm

Recommended Content:

Office of the Armed Forces Medical Examiner

DoD Addendum to the Department of Health and Human Services Federalwide Assurance for the Protection of Human Subjects

Form/Template
8/20/2009

This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DoD policies and requirements since the DHHS FWA does not identify DoD requirements.

Recommended Content:

Research Regulatory Oversight Office

Smallpox Vaccine Take Check Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Smallpox Vaccine Sick Call Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Researcher Responsibility Form

Form/Template
4/16/2009

The Office of the Under Secretary of Defense for Personnel and Readiness requires that all research investigators (principal investigators as well as associate investigators) engaged in research with one of its institutions explicitly acknowledge and accept responsibility for protecting the rights and welfare of human research subjects as stated therein.

Recommended Content:

Research Regulatory Oversight Office

Disposition of Remains Election Statment Initial Notification of Identified Partial Remains

Form/Template
4/1/2009

Used to record disposition of remains desired by the person authorized to direct disposition of remains (PADD).

Recommended Content:

Office of the Armed Forces Medical Examiner

TMDS DD Form 2930 (PIA)

Form/Template
11/1/2008

Privacy Impact Assessment (PIA) for the Theater Medical Data Store (TMDS).

Smallpox Vaccine 30-day Diary Card

Form/Template
2/7/2008

This form is used to track symptoms after receiving the smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events
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