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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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M2 Access Instruction

Form/Template
10/27/2017

Instructions for accessing M2

Recommended Content:

MDR, M2, ICDs Functional Support | M2 Functional Specifications

CS SCE 2875

Form/Template
10/27/2017

Form 2875 for access to Corporate Node

PDS Troubleshooting Feedback Form

Form/Template
10/23/2017

The PDS feedback form is available to MTF pharmacy point of contacts that have questions or concerns about the new PDS project. The form includes necessary fields for the PASS team to troubleshoot.

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

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

Steps to take for Potentially Compromised Vaccine Event

Form/Template
8/4/2017

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

Anthrax Vaccine in Pregnancy Registry Referral Form

Form/Template
7/1/2017

Form for providers to refer patients who were exposed to anthrax vaccine while pregnant to the BioThrax Vaccine in Pregnancy Registry.

Recommended Content:

Anthrax | Pregnancy Information

340b Verification Form

Form/Template
6/30/2017

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

VAERS Smallpox Pregnancy Supplemental Form

Form/Template
6/29/2017

Form for providers to refer patients who were exposed to smallpox vaccine while pregnant to the Smallpox Vaccine in Pregnancy Registry.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events | Pregnancy Information

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

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