Skip to main content

Military Health System

Test of Sitewide Banner

This is a test of the sitewide banner capability. In the case of an emergency, site visitors would be able to visit the news page for addition information.

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.

Looking for an official Defense Health Agency Form?

If you're having trouble finding what you're looking for, consider using fewer words in your search criteria. Results are limited to content that matches all terms in the search field.

We found -

Specify Date Range (Optional):
Select Content Types (Optional):
Current Filters. Click a Filter to Remove It
Date Range:

Request for Autopsy Report and Supplemental Information

Form/Template
1/3/2023

Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.

Department of Defense Suicide Event Report

Form/Template
12/2/2022

Privacy Impact Assessment for the DoDSER 2.0, surveillance system designed to gather standardized risk and protective factor information for suicide events across multiple domains.

Financial Management Information System

Form/Template
12/2/2022

Privacy Impact Assessment for the Financial Management Information System, an integrated resource execution system that enables the Military Health System Resource Management users to rapidly compile operational data from disparate internal and external legacy financial, acquisition, logistics, personnel, and payroll data sources.

Armed Forces Health Longitudinal Technology Application (AHLTA)

Form/Template
11/15/2022

Privacy Impact Assessment for AHLTA, a fully integrated health care information system used in Department of Defense Military Treatment Facilities and clinics.

VAERS Smallpox Pregnancy Supplemental Form

Form/Template
11/14/2022

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

Pentax endoPRO iQ

Form/Template
11/10/2022

Pentax endoPRO iQ is a video and imaging application and the primary function is the maintenance/storage of patient and procedure data.

Joint Medical Operations Program Nomination/Registration Request

Form/Template
11/7/2022

This form is used to provide the Defense Medical Readiness Training Institute (DMRTI) with information required to complete course registration in order to provide student and DMRTI full course attendance as well as the awarding of Continuing Education credit (CME/CNE).

TRICARE Dispute Resubmission Form

Form/Template
10/24/2022

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

DHA Form 249: Pharmacy Data Warehouse Data Report Request Form

Form/Template
10/7/2022

Web MEDCASE Requirements and Execution PIA

Form/Template
10/5/2022

The Web Medical Care Support Equipment (MEDCASE) Requirements and Execution (WebMRE) version 1.x system is a database and web application that is developed for the Defense Health Agency's (DHA's) Integrated Clinical Systems Program Management Office (ICS PMO). The WebMRE system is a Platform as a Service (PaaS) hosted on the DHA's Data Center Operations Branch (DCOPS) virtual environment. The WebMRE system is designed to provide detailed information, requirements data, and execution status to assist in the management and control of the MEDCASE/Super Capital Expense Equipment Program (SuperCEEP). WebMRE system will provide detailed information of Medical Device Equipment located in the Army's Medical Treatment Facilities (MTF’s) to assist with the requirements generation, life-cycle management and Planning, Programming, Budgeting and Execution (PPBE) process for Army Medical Equipment and general users. The system was a legacy application that was developed in Oracle 11g and was upgraded to Oracle 12c. The system was migrated from legacy application of Cold Fusion to ASP.NET MVC 5 Framework. The WebMRE System application is a database to manage the data captured via user interface. Front end of the application is developed using ASP.NET. The backend will use ORACLE 12c.

DHA Form 301: Freezer Temperature Log - Celsius

Form/Template
10/1/2022

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

DHA Form 304: Refrigerator Temperature Log - Fahrenheit

Form/Template
10/1/2022

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

DHA Form 302: Freezer Temperature Log - Fahrenheit

Form/Template
10/1/2022

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

DHA Form 303: Refrigerator Temperature Log - Celsius

Form/Template
10/1/2022

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

59th MDW Wilford Hall WHEN MEDCOI PIA

Form/Template
9/20/2022

The 59th MDW Wilford Hall (WHEN)_MEDCOI is also known as Wilford Hall Ambulatory Surgical Center (WHASC) Site and Wilford Hall Enterprise Network (WHEN) is an outpatient Medical Treatment Facility (MTF) supporting over 240,000 enrolled Tri-Service Beneficiaries and more than 6,000 military members, civilian personnel, residents, and students. The WHEN Enclave consists of End User Devices (EUDs), switches, appliances, and the data center. The WHEN provides all environmental controls such as light, power, Heating Ventilation Air Conditioning, and physical security for the data center. Co-located and Managed Co-located systems within the data center include systems and applications that contain Protected Health Information (PHI) and Personally Identifiable Information (PII) data. Data Network Connectivity (DNC), Enterprise Management System (EMS), and the Network Protection Suite are services controlled and managed by DHA and are not included in the authorization boundary.

Page 3 of 25  showing items 31 - 45
First < 1 2 3 4 5  ... > Last 
Last Updated: July 11, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery