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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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Freezer Temperature Log - Fahrenheit

Form/Template
7/12/2018

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Celsius

Form/Template
7/11/2018

Temperature log for refrigerators storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
7/11/2018

Monitoring the temperature of your vaccine storage unit is required at least twice a day, and should be logged using this form.

Recommended Content:

Vaccine Storage and Handling

Emergency Vaccine Retrieval and Storage Plan Worksheet

Form/Template
7/10/2018

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

PIA Navy Medicine Online

Form/Template
6/8/2018

This Privacy Impact Assessment is from Navy Medicine Online. The Navy Medicine Online (NMO) serves a vital role in the overall process of collecting, analyzing, and brokering medical readiness data to and from critical and authoritative Department of Defense (DoD) data sources into one common operational view that can be drilled down into individual units and personnel as needed. Data is only provided to DoD entities.

DHA-GL Worksheet-02: Pre-Authorization Request

Form/Template
5/31/2018

Defense Health Agency - Great Lakes Worksheet (DAH-GL Worksheet-02) This worksheet is used to request pre-authorization for medical care for Reserve Component Members

Dental Common Access System

Form/Template
5/21/2018

Dental Common Access System (DENCAS)

TRICARE Online (TOL)

Form/Template
5/21/2018

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the TRICARE Online (TOL) system.

AHLTA

Form/Template
5/21/2018

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the AHLTA system.

Veterinary Services Systems Management

Form/Template
5/21/2018

Veterinary Services Systems Management (VSSM)

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
5/16/2018

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

Epidemiology and Analysis Data Request Approval Process (RAP) Form

Form/Template
5/3/2018

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis Data Request Approval Process (RAP) Form

UF BCF ECF OTC Request Form Feb 2018

Form/Template
2/26/2018

MTF Drug Request Review Form

PDTS Data Report Request Form

Form/Template
2/13/2018

The PDTS reports function is constantly evolving and as we continue to find new applications for the data collected by PDTS, the reports function will be modified to meet those demands.

PDTS Report Request Form

Form/Template
2/13/2018

This form is used to assist providers in the identification of patients who have received prescriptions for controlled substances over a given period of time and provide them with an automated process to analyze the data.

Recommended Content:

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

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