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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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Account Authorization Request Form

Form/Template
11/7/2017

Fillable form for access requests to MDR data.

Recommended Content:

MDR, M2, ICDs Functional Support | MDR Functional Specifications

M2 Access Instruction

Form/Template
10/27/2017

Instructions for accessing M2

CS SCE 2875

Form/Template
10/27/2017

Form 2875 for access to Corporate Node

PDS Troubleshooting Feedback Form

Form/Template
10/23/2017

The PDS feedback form is available to MTF pharmacy point of contacts that have questions or concerns about the new PDS project. The form includes necessary fields for the PASS team to troubleshoot.

SCE AARF

Form/Template
10/4/2017

SAS COMPUTING ENVIRONMENT (SCE) Account Authorization Request Form (AARF)

CS SCE Access Instructions

Form/Template
10/4/2017

Instructions for completing the necessary forms to apply for a MDR user's account

VAERS Smallpox Pregnancy Supplemental Form

Form/Template
6/29/2017

Form for providers to refer patients who were exposed to smallpox vaccine while pregnant to the Smallpox Vaccine in Pregnancy Registry.

Recommended Content:

Smallpox (ACAM2000) | Smallpox Vaccine-Associated Adverse Events | Pregnancy Information

Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA)

Form/Template
6/5/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA).

Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DoD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.

Protected Health Information Management Tool (PHIMT)

Form/Template
6/1/2017

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Protected Health Information Management Tool (PHIMT) system.

DHA-GL Worksheet-01: Medical Eligibility Verification

Form/Template
4/10/2017

Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members

DHA-GL Worksheet-06: Surgical Pre-Authorization Request

Form/Template
4/10/2017

Defense Health Agency - Great Lakes Worksheet (DHA-GL Worksheet-06) This form is used to request pre-authroization for surgical care from the DHA, Great Lakes.

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
4/6/2017

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

Data Sharing Agreement (DSA) - Modification Request

Form/Template
1/30/2017

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

Recommended Content:

Submit a Data Sharing Application

DSADHA Certification Data Disposition 20180611

Form/Template
1/30/2017

This template is for the sole purpose of certifying that data used in connection with a Data Sharing Agreement (DSA) that was executed with the DHA Privacy and Civil Liberties Office (Privacy Office) has been appropriately disposed of in a timely manner.

Recommended Content:

Submit a Data Sharing Application
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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