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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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PEPR Account Activation Request Form

Form/Template
7/28/2015

This form is required for all users to complete prior to receiving access to the Patient Encounter and Reporting (PEPR) application.

RxSafe RxVault

Form/Template
7/20/2015

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the RxSafe RxVault system.

STARS

Form/Template
7/20/2015

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the STARS system.

Audio Metric Database System (AUDBASE) 2.3

Form/Template
7/20/2015

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the Audio Metric Database System (AUDBASE) 2.3 system.

Armed Forces Billing and Collection Utilization Solution (ABACUS)

Form/Template
6/29/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Armed Forces Billing and Collection Utilization Solution (ABACUS) system.

Consent Checklist

Form/Template
5/20/2015

DOD Directive 3216.02 defines research involving a human being as an experimental subject as an activity, for research purposes, where there is an intervention or interaction with a human being for the primary purpose of obtaining data regarding the effect of the intervention or interaction. Examples of interventions or interactions include, but are not limited to, a physical procedure, a drug, a manipulation of the subject or subject's environment, the withholding of an intervention that would have been undertaken if not for the research purpose.

MHS IM-IT Submission Form

Form/Template
5/18/2015

Fill out the MHS IM-IT Submission Form to submit an idea to foster change to an IM/IT capability, policy/process, or system.

Patient Global Impression Change Scale

Form/Template
5/1/2015

Form filled out by patients to rate their changes in activity, symptoms, emotions and quality of life.

Neurobehavioral Symptom Inventory Form

Form/Template
4/30/2015

Form used by providers to question patients about their symptoms

Military Acute Concussion Evaluation 2012

Form/Template
4/30/2015

Use this form to screen for concussions

Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE)

Form/Template
4/23/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) system.

Defense Medical Accessions Computing System (DMACS)

Form/Template
4/17/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Defense Medical Accessions Computing System (DMACS) system.

Armed Forces DNA Identifcation Laboratory Casework Request

Form/Template
4/10/2015

Use this form to obtain information/specimens needed to evaluate and document forensic DNA testing requests.

Fraud and Abuse Correspondence Tracking System (FACTS)

Form/Template
4/6/2015

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Fraud and Abuse Correspondence Tracking System (FACTS) system.

Liebel Flarsheim Direct Digital Imaging System (LFDDIS)

Form/Template
3/19/2015

This Air Force Medical Support Agency (AFMSA) Privacy Impact Assessment (PIA) summarizes the Liebel Flarsheim Direct Digital Imaging System (LFDDIS).

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Last Updated: July 11, 2023
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