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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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Request for Autopsy Report and Supplemental Information

Form/Template
2/15/2019

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

Recommended Content:

Office of the Armed Forces Medical Examiner

DHAJ7 Event Planning Intake Form

Form/Template
2/11/2019

DHAJ7_Event Planning Intake Form_v7-15 (003)

Defense Health Agency J7 Continuing Education Program Office Continuing Education Application

Form/Template
2/11/2019

Defense Health Agency J7 Continuing Education Program Office Continuing Education Application v1-5

Request for DoD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary

Form/Template
1/2/2019

Please attach MTF P&T Committee comments & meeting minutes, an explanation of the rationale for the request, copies of supporting clinical evidence, and anything else that needs to be considered by the DoD P&T Committee.

Recommended Content:

TRICARE Formulary

Guidelines for Reporting Breaches

Form/Template
11/27/2018

This document outlines the DoD reporting and notification requirements for breaches.

Recommended Content:

Breaches of PII and PHI

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
10/23/2018

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

OIG DD2949 Whistleblower Complaint Form

Form/Template
7/26/2018

This is a form that users will download and either FAX or mail to file a complaint to the DHA IG office.

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)

AHLTA

Form/Template
5/21/2018

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

TRICARE Online (TOL)

Form/Template
5/21/2018

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

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