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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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Program Integrity Report Request Form

Form/Template
2/13/2018

This form is designed to accommodate requests for patient, drug, provider, and pharmacy profiles. If you need assistance completing this form please call the number shown above. The PASS cannot act on any report request until the form has been approved and the requestor has agreed with the method of extract and the structure of the report.

Request for Deployment (P-MART) or Warriors in Transition (WTU-MART)

Form/Template
2/13/2018

Use this form to request sensitive data in support of deployments (P-MART) or warriors in transition (WTU-MART).

Recommended Content:

WTU P-MART | P-MART

Smallpox Vaccine Screening Form

Form/Template
2/8/2018

Each potential recipient of smallpox vaccine must complete this official screening form and it must be signed by a licensed health care provider prior to vaccination.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Storage Unit Sticker Template

Form/Template
2/1/2018

Some resources you can use to protect your vaccine storage unit and warn staff to not turn off power to the unit.

Recommended Content:

Vaccine Storage and Handling

TRICARE Prime Remote Determination of Enrollment Eligibility

Form/Template
1/2/2018

Submit this form if you believe that one or more of the exceptions to the eligibility criteria for TRICARE Prime Remote enrollment are met. Only service members or unit commanders can submit this form.

JMOC or JMPT Nomination Form

Form/Template
12/29/2017

JMOC - JMPT Nomination Form

Amputation Care ECHO Facilitation Scorecard

Form/Template
11/22/2017

Use this form to score the facilitator.

Recommended Content:

Clinical Affairs

Patient Queuing and Notification System (PQNS)

Form/Template
11/15/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes Patient Queuing and Notification System (PQNS) system.

Coagulation Clinic (CoagClinic)

Form/Template
11/15/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Coagulation Clinic (CoagClinic) system.

Account Authorization Request Form

Form/Template
11/7/2017

Fillable form for access requests to MDR data.

Recommended Content:

MDR, M2, ICDs Functional Support | MDR Functional Specifications

M2 Access Instruction

Form/Template
10/27/2017

Instructions for accessing M2

Recommended Content:

MDR, M2, ICDs Functional Support | M2 Functional Specifications

CS SCE 2875

Form/Template
10/27/2017

Form 2875 for access to Corporate Node

PDS Troubleshooting Feedback Form

Form/Template
10/23/2017

The PDS feedback form is available to MTF pharmacy point of contacts that have questions or concerns about the new PDS project. The form includes necessary fields for the PASS team to troubleshoot.

Steps to take for Potentially Compromised Vaccine Event

Form/Template
8/4/2017

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

DHA Privacy Office Standard Contract Language

Form/Template
7/6/2017

This Section addresses the Contractor’s requirements under The Privacy Act of 1974 (Privacy Act), The Freedom of Information Act (FOIA), and The Health Insurance Privacy and Accountability Act (HIPAA) as set forth in applicable statutes, implementing regulations and DoD issuances.

Recommended Content:

Privacy and Civil Liberties | DHA Privacy Contract Language
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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