Back to Top Skip to main content
Alert Arrow ALERT!!

The federal government is currently experiencing an emergency shutdown furlough which may affect up to 850,000 federal employees and disrupt some services across the Military Health System.

  • For information about the TRICARE health plan and getting care during the shutdown furlough, visit www.tricare.mil/shutdown.
  • Federal employees can visit the Office of Personnel Management's guidance during the shutdown furlough.
  • Active duty military service personnel are not affected by the shutdown furlough and should report to work as usual. Visit Defense.gov for further guidance. 

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.

MTF ePharmacy NCPDP NPI Request Form

Form/Template
9/9/2016

Use this form to requests a new ePharmacy NCPDP/NPI number

Zeiss FORUM

Form/Template
8/12/2016

Zeiss FORUM PIA summary

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

Vendor Information Form

Form/Template
7/27/2016

The Vendor Information Form provides a standard way to collect your ideas, problem statements, and/or proposed solution sets for defense health IT.

Recommended Content:

Technology | Health IT Research and Innovation | Health IT Research and Innovation | Health IT Research and Innovation | Health IT Research and Innovation

Department of Defense Consolidated Cancer Registry (CCR)

Form/Template
7/21/2016

Department of Defense Consolidated Cancer Registry (CCR) System PIA summary

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

MTF ePharmacy Demographic Change Request Form

Form/Template
7/7/2016

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.

TRICARE Webinar Feedback

Form/Template
6/27/2016

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."

Military Health System Data Repository

Form/Template
6/23/2016

Military Health System (MHS) Data Repository (MDR) PIA

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

Defense and Veterans Eye Injury and Vision Registry

Form/Template
6/22/2016

PIA for the Defense and Veterans Eye Injury and Vision Registry (DVEIVR)

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

Family Reference Collection Form

Form/Template
6/22/2016

This form is used to establish a DNA reference specimen repository and database of information from kindred family members of unaccounted for/unidentified service members or other individuals needing to be identified. DNA will be extracted from a biological specimen or personal effect and used in identifying human remains.

Recommended Content:

DoD DNA Operations | Repository of Specimen Samples for the Identification of Remains

Surgery Scheduling System (S3)

Form/Template
6/20/2016

PIA for the Surgery Scheduling System S3

Recommended Content:

Privacy and Civil Liberties | Privacy Impact Assessments

Smallpox Vaccine Screening Form

Form/Template
6/17/2016

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

DVEIVR PIA

Form/Template
6/15/2016

Privacy Impact Assessment (PIA) Summary for Defense and Veterans Eye Injury and Vision Registry (DVEIVR)

MDR PIA

Form/Template
6/15/2016

Privacy Impact Assessment (PIA) Summary for the Military Health System (MHS) Data Repository (MDR)

AFMES Form 25: Histology Request and Specimen Storage

Form/Template
6/1/2016

Use this form to obtain information/specimens needed for histology tissue processing and/or specimen storage.

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner

TRICARE Dispute Resubmission Form

Form/Template
5/26/2016

TRICARE Dispute Resolution Form for manufacturers. For use on resubmitted rejected disputes.

<< < 1 2 3 4 5  ... > >> 
Showing results 46 - 60 Page 4 of 19

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

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing: Download a PDF Reader or learn more about PDFs.