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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Fillable form for access requests to MDR data.
Recommended Content:
Instructions for accessing M2
Form 2875 for access to Corporate Node
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.
SAS COMPUTING ENVIRONMENT (SCE) Account Authorization Request Form (AARF)
Instructions for completing the necessary forms to apply for a MDR user's account
Form for providers to refer patients who were exposed to smallpox vaccine while pregnant to the Smallpox Vaccine in Pregnancy Registry.
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Enterprise Web AMEDD Electronic Forms Support System (WEB-AEFSS) (EWA).
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the DoD Women, Infants, and Children Overseas Participant Information Management System (WIC PIMS) system.
This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Protected Health Information Management Tool (PHIMT) system.
Defense Health Agency, Great Lakes Worksheet (DHA-GL Worksheet-01) This worksheet is used to confirm eligibility of Reserve Component Members
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.
Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.
The Data Sharing Agreement Modification Request template is used when requesting the modification of an executed DSA.
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.
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.