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Military Health System

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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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UBO Compliance Plan Template

Form/Template
9/15/2015

This Compliance Plan is a template, not a final document. You should edit it to include your MTF’s specific processes, procedures, policies, and information as appropriate.

MSA Claim Post-Submission Review Worksheet

Form/Template
9/15/2015

Use this review worksheet to help establish a consistent UBO billing submission framework.

Memorandum Template for a Uniform Business Office Compliance Plan

Form/Template
9/15/2015

Use this template to develop your memorandum to create a UBO Compliance Plan.

MAC Claim Post-Submission Review Worksheet

Form/Template
9/15/2015

Use this review worksheet to help establish a consistent UBO billing submission framework.

Annual Review of Compliance Program Effectiveness Checklist

Form/Template
9/15/2015

The UBO Compliance Officer will regularly review the implementation and execution of the compliance program elements. This review will be conducted as least annually and will include an assessment of each of the basic elements individually, as well as the overall success of the program. It will help identify any weaknesses in your compliance program and implement appropriate changes. A copy of this review should be provided to the Base Commander and UBO Service Manager.

UBO Compliance Audit Checklist

Form/Template
9/15/2015

This Compliance Audit Checklist Template is an element of our MTF’s Internal Control Review and is part of your compliance program. It covers the basic points of TPC, MSA, and MAC programs. It can also be used in business case analysis/reengineering initiatives for the Uniform Business Office.

TPCP Claim Post-Submission Review Worksheet

Form/Template
9/15/2015

Use this review worksheet to help establish a consistent UBO billing submission framework.

AHLTA-Theater/AHLTA-Mobile/Mobile Computing Capability (AHLTA-T/AHLTA-M/MCC)

Form/Template
9/9/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the AHLTA-Theater/AHLTA-Mobile/Mobile Computing Capability (AHLTA-T/AHLTA-M/MCC) system.

Coding and Compliance Editor (CCE)

Form/Template
8/11/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Coding and Compliance Editor (CCE) system.

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: Namenda XR

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for Namenda XR

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: Acne Isotretinoids

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for Acne Isotretinoids

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: GI-2 Agents, Miscellaneous

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for GI-2 Agents, Miscellaneous

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: Antirheumatics Injectable Methotrexate

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for Antirheumatics Injectable Methotrexate

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: Namzaric

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for Namzaric

UFBPA Appendix for the Nov 2015 DOD P&T Meeting: ADHD Stimulants

Form/Template
8/7/2015

UFBPA Appendix for the Nov 2015 DOD P&T Meeting for ADHD Stimulants

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Last Updated: July 11, 2023
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