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Military Health System

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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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Required Representations for Research on Decedents Information


Use this form if the researcher intends to conduct research that is solely on the protected health information (PHI) of decedents, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and Department of Defense (DOD) Health Information Privacy Regulation (DOD 6025.18-R).

DHA Privacy Board Application for a Waiver of Authorization or an Altered Authorization


Use this form if the researcher has not received documentation from an Institutional Review Board (IRB) or HIPAA Privacy Board approving a waiver or alteration of Authorizations and reasons exist that make it impractical or impossible for the researcher to obtain Authorizations from each research participant, the PI may submit an Application for a Waiver of Authorization or an Altered Authorization. A DHA Privacy Board member will conduct an expedited review of the completed application and determine whether to approve or deny an altered Authorization or a full or partial waiver of Authorizations.

Request for Mitochondrial DNA Sequence Report


Use this form to request a copy of your mitochondrial DNA type to help recover family member remains.

CMS-1500 Health Insurance Claim Form


Health Insurance Claim form for Medicare Professional Services.

Brand over Generic Prior Authorization Form


This form should be completed and signed by the prescriber to request prior authorization to use a brand name drug instead of a generic equivalent.

Medicare Enrollment Application, CMS-855A


This form is for institutional providers to apply for enrollment in the Medicare program or make a change in their enrollment information.

Individual Investigator Agreement


This form is a tool that can be used when a collaborating investigator is not part of an institution with a federal assurance.

Disposition of Organs Retained for Extended Examination


Use this form to grant permission to the Armed Forces Medical Examiner System to retain organs for an extended examination to determine cause of death.

Institutional Agreement for IRB Review


This form should be used when an institution will be engaged in human subject research and will use an Institutional Review Board (IRB) that is not organizationally or legally part of the institution.

Supplemental Health Care Program Worksheet


Use this worksheet when referring a service member under the Supplemental Health Care Program.

Sudden Unexplained Infant Death Investigation Reporting Form


Designed to help investigative agencies to better understand the circumstances and factors contributing to unexplained infant (less than 1 year old) deaths. View more information about the form at:

DOD Addendum to the Department of Health and Human Services Federalwide Assurance for the Protection of Human Subjects


This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DOD policies and requirements since the DHHS FWA does not identify DOD requirements.

Smallpox Vaccine Sick Call Medical Note


This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Smallpox Vaccine Take Check Medical Note


This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Researcher Responsibility Form


The Office of the Under Secretary of Defense for Personnel and Readiness requires that all research investigators (principal investigators as well as associate investigators) engaged in research with one of its institutions explicitly acknowledge and accept responsibility for protecting the rights and welfare of human research subjects as stated therein.

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Last Updated: July 19, 2022
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