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.
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This form is used to identify additional Notes on Problems, Issues or Concerns of Patient or Provider related to Vaccine Assessment or Follow-up.
Recommended Content:
Form and CMS 1450 Data Set Medicare Claim Processing Manual Instructions for Institutional Services
To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
This form is used to record DU Bioassay/Fragment Testing and Results Information
This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care.
This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care to you.
This form is to provide the patient with a means to request a restriction on the use and disclosure of his/her protected health information.
This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.
Use this form to submit your Third Party Collections Program reports.
DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101
The appearance of hyperlinks does not constitute endorsement by the Defense Health Agency of non-U.S. Government sites or the information, products, or services contained therein. Although the Defense Health Agency may or may not use these sites as additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may find at these locations. Such links are provided consistent with the stated purpose of this website.