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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 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 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

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 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: 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: 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.

CIS Essentris PIA

Form/Template
8/19/2019

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

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

Theater Medical Information Program-Joint Composite Health Care System Caché (TC2).

Form/Template
8/5/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Theater Medical Information Program-Joint Composite Health Care System Caché (TC2).

Air Force Medical Omnibus Web Applications (AFMOWAP)

Form/Template
7/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Air Force Medical Omnibus Web Applications (AFMOWAP)

Defense Occupational and Environmental Health Readiness System - Industrial Hygiene (DOEHRS-IH)

Form/Template
7/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Defense Occupational and Environmental Health Readiness System - Industrial Hygiene (DOEHRS-IH) system.

Armed Forces Medical Examiner System Consultation Request Form

Form/Template
5/22/2019

Medical information received is considered during the consultative process and is used to form a database for education and research in pathology.

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner

Armed Forces Billing And Collection Utilization Solution - Amazon Web Services (ABACUS-AWS)

Form/Template
4/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Armed Forces Billing and Collection Utilization Solution (ABACUS) system.

Enterprise Blood Management System (EBMS_T)

Form/Template
4/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Blood Management System (EBMS_T) system.

Donor -Enterprise Blood Management System (EBMS_D)

Form/Template
4/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Donor -Enterprise Blood Management System (EBMS_D) system.

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