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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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Sudden Unexplained Infant Death Investigation Reporting Form

Form/Template
2/1/2010

Designed to help investigative agencies to better understand the circumstances and factors contributing to unexplained infant (less than 1 year old) deaths. View more information about the form at: http://www.cdc.gov/sids/SUIDRF.htm

Recommended Content:

Office of the Armed Forces Medical Examiner

DoD Addendum to the Department of Health and Human Services Federalwide Assurance for the Protection of Human Subjects

Form/Template
8/20/2009

This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DoD policies and requirements since the DHHS FWA does not identify DoD requirements.

Recommended Content:

Research Regulatory Oversight Office

Smallpox Vaccine Take Check Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Smallpox Vaccine Sick Call Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Researcher Responsibility Form

Form/Template
4/16/2009

The Office of the Under Secretary of Defense for Personnel and Readiness requires that all research investigators (principal investigators as well as associate investigators) engaged in research with one of its institutions explicitly acknowledge and accept responsibility for protecting the rights and welfare of human research subjects as stated therein.

Recommended Content:

Research Regulatory Oversight Office

Disposition of Remains Election Statment Initial Notification of Identified Partial Remains

Form/Template
4/1/2009

Used to record disposition of remains desired by the person authorized to direct disposition of remains (PADD).

Recommended Content:

Office of the Armed Forces Medical Examiner

TMDS DD Form 2930 (PIA)

Form/Template
11/1/2008

Privacy Impact Assessment (PIA) for the Theater Medical Data Store (TMDS).

Smallpox Vaccine Screening or Medical Note Continuation Page

Form/Template
2/7/2008

This form is used to identify additional Notes on Problems, Issues or Concerns of Patient or Provider related to Vaccine Assessment or Follow-up.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Smallpox Vaccine 30-day Diary Card

Form/Template
2/7/2008

This form is used to track symptoms after receiving the smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

CMS-1450 UB-04 Uniform Bill

Form/Template
3/1/2007

Form and CMS 1450 Data Set Medicare Claim Processing Manual Instructions for Institutional Services

Recommended Content:

Health Plan and Policy Billing Guidelines

DD Form 2802: Report of Medical Examination

Form/Template
1/10/2005

To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.

Recommended Content:

Medical Evaluation Board | Physical Evaluation Board

OIF DU Exposure Semi-Annual Progress Report

Form/Template
9/30/2004

This form is used to record DU Bioassay/Fragment Testing and Results Information

Depleted Uranium Questionnaire

Form/Template
2/1/2004

This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care.

Recommended Content:

DU Medical Follow-Up Program

Health Survey, DD Form 2872-1 Test

Form/Template
2/1/2004

This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care to you.

DD Form 2871: Request to Restrict Medical or Dental Information Form

Form/Template
12/1/2003

This form is to provide the patient with a means to request a restriction on the use and disclosure of his/her protected health information.

Recommended Content:

How HIPAA Protects You
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