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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.

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.

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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

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

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

Coagulation Clinic (CoagClinic)

Form/Template
11/15/2017

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

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.

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.

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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