Bio-Rad D-100 Hemoglobin Testing System v1.x_A&I
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 five 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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Popular Forms & Templates
Neurobehavioral Symptom Inventory Form
DHA-GL Worksheet 02: Pre-Authorization Request
DHA-GL Worksheet 01: Medical Eligibility Verification
Medical Readiness Decision Support System (MRDSS)
Patient Global Impression Change Scale
Financial Management Information System
VA/DOD Clinical Practice Guideline for Tinnitus
MHS Service Help Desk
DHA Privacy Office Standard Contract Language
DHA-GL Worksheet 03: Formal Appeal Request
Form/Template
Oct. 27, 2020
DHA Privacy Office Standard Contract Language
.PDF |
267.81 KB
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.
Form/Template
Oct. 1, 2020
HIPAA Safeguard Review of Non-Federal Systems (HSR)
.PDF |
819.78 KB
The HIPAA Safeguard Review of Non-Federal Systems (HSR) is used when data obtained through a DSAA will be stored, transmitted, processed, or otherwise maintained on a non-federal information system.
Form/Template
April 1, 2020
MDR Special Justification Form
.PDF |
99.98 KB
Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.
Form/Template
March 1, 2020
Routine Immunization Screening Form Adult
Routine immunization screening form for Adults
Form/Template
March 1, 2020
Routine Immunization Form Pediatric
To determine whether your child can safely receive a routine immunization.
Form/Template
Nov. 20, 2019
DHA-GL Worksheet 41: DOD/VA MOA Inpatient-Outpatient Continued Stay Review
.PDF |
448.99 KB
Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Nov. 20, 2019
EACE Data Request Form
.PDF |
184.74 KB
Form for users to fill out to request information/data from EACE
Form/Template
Nov. 14, 2019
DHA-GL Worksheet : Discharge Summary
.PDF |
365.17 KB
Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Nov. 14, 2019
DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization VAMC Richmond Only
.PDF |
2.08 MB
To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Oct. 4, 2019
Request for DOD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary
.PDF |
43.32 KB
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.
Form/Template
Aug. 29, 2019
DHA-GL Worksheet 07a: DOD/VA MOA Continued Stay for SCI-TBI-Blind Rehab
.PDF |
1.92 MB
To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Aug. 29, 2019
DHA-GL Worksheet 08: DOD/VA MOA SCI-TBI-Blind DME Request Worksheet
.PDF |
1.36 MB
To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Aug. 29, 2019
DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab
.PDF |
1.95 MB
Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Aug. 29, 2019
DHA-GL Worksheet 07: DVA/DOD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab STAR Program
.PDF |
1.17 MB
Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form/Template
Aug. 29, 2019
DHA-GL: How to Submit Discharge Summary notification
.PDF |
481.03 KB
This process guides references how to submit Discharge Summary notification from Inpatient or Outpatient Medical Care at a VA Facility under DOD/VA Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.
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