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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The HIPAA Safeguard Review of Non-Federal Systems (HSR) is used when data obtained through a DSAA will be stored, transmitted, processed, or otherwise maintained on a non-federal information system.
Recommended Content:
Dental Common Access System (DENCAS)
Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.
A screening checklist for contraindications to vaccines for adults.
A screening checklist for contraindications to vaccines for children and teens.
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.
Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains
340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.
Nomination form for JMOC, JMPT, and JHOC
Student nomination form for both JMOCs and JMPT.
Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.
Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form
Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.
Form for users to fill out to request information/data from EACE
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.