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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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DHA-GL: How to Submit Request for Durable Medical Equipment Pre- Authorization

Form/Template
8/29/2019

This process guides references how to submit Request for Durable Medical Equipment for Pre- Authorization of Inpatient or Outpatient Medical Care at a VA Facility under DVA/DoD Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

DHA-GL Worksheet 07a: DVA/DoD MOA Continued Stay for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

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

DHA-GL: How to Submit Discharge Summary notification

Form/Template
8/29/2019

This process guides references how to submit Discharge Summary notification from Inpatient or Outpatient Medical Care at a VA Facility under DVA/DoD Memorandum of Agreement (MOA) for Active Duty Service Members with SCI, TBI and/or Blind Diagnoses to Defense Health Agency Great Lakes DHA-GL.

DHA-GL Worksheet 08: DVA/DoD MOA SCI-TBI-Blind DME Request Worksheet

Form/Template
8/29/2019

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

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab STAR Program

Form/Template
8/29/2019

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

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization for SCI-TBI-Blind Rehab

Form/Template
8/29/2019

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

Initial/Annual Competency Assessment Checklist: INFLUENZA VACCINE ADMINISTRATION

Form/Template
8/26/2019

A checklist to evaluate competency in administering the influenza vaccine, to include customer service, patient screening and education, and administration technique and procedures.

Recommended Content:

Influenza Seasonal

Potentially Compromised Temperature Sensitive Medical Products (PC TSMP) Worksheet

Form/Template
8/21/2019

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

CIS Essentris PIA

Form/Template
8/19/2019

This Privacy Impact Assessment (PIA) documents compliances for CIS-Essentris

PC TSMP Worksheet (Continuation Sheet)

Form/Template
8/13/2019

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Freezer Temperature Log - Celsius

Form/Template
8/12/2019

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Steps to take for Potentially Compromised Vaccine Event

Form/Template
8/12/2019

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/12/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Storage Unit Sticker Template

Form/Template
8/12/2019

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

Refrigerator Temperature Log - Celsius

Form/Template
8/12/2019

Temperature log for refrigerators storing vaccines.

Recommended Content:

Vaccine Storage and Handling
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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