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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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Smallpox Vaccine Screening Form

Form/Template
3/2/2020

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 (ACAM2000) | Smallpox Vaccine-Associated Adverse Events

AFRSSIR Supply Order Request

Form/Template
2/12/2020

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner | DoD DNA Operations | Repository of Specimen Samples for the Identification of Remains

340b Verification Form

Form/Template
2/7/2020

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

DMRTI JOP Nomination Form

Form/Template
1/30/2020

Nomination form for JMOC, JMPT, and JHOC

Recommended Content:

Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course (JMOC) | Joint Medical Planning Tool Course | Defense Medical Readiness Training Institute | Combat Support | Defense Medical Readiness Training Institute | Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course | Joint Medical Planning Tool Course

DMRTI JOP Student Nomination_JAN20

Form/Template
1/22/2020

Student nomination form for both JMOCs and JMPT.

Form 543

Form/Template
1/2/2020

DMRTI JOP Student Nomination

Form/Template
12/11/2019

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

AFHSB 501 Request Form

Form/Template
11/26/2019

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form

DHA-GL Worksheet 41: DoD/VA MOA Inpatient-Outpatient Continued Stay Review

Form/Template
11/20/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

EACE Data Request Form

Form/Template
11/20/2019

Form for users to fill out to request information/data from EACE

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization VAMC Richmond Only

Form/Template
11/14/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet : Discharge Summary

Form/Template
11/14/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

Data Sharing Agreement Application (DSAA)

Form/Template
10/25/2019

The Data Sharing Agreement Application (DSAA) is used when requesting data from systems that are owned and/or managed by DHA.

Recommended Content:

Submit a Data Sharing Application

Data Sharing Agreement (DSA) - Renewal Request Template 2019.10.28

Form/Template
10/25/2019

The Data Sharing Agreement Renewal Request template is used when requesting the renewal of an executed DSA.

Recommended Content:

Submit a Data Sharing Application

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

Form/Template
10/4/2019

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

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