MDR Special Justification Form

Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.

DD Form 3111: Routine Immunization Screening Form: Adults

A screening checklist for contraindications to vaccines for adults.

DD Form 3110: Routine Immunization Screening Form: Pediatric

A screening checklist for contraindications to vaccines for children and teens.

Smallpox Vaccine Screening Form

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.

AFRSSIR Supply Order Request

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

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

DMRTI JOP Student Nomination_JAN20

Student nomination form for both JMOCs and JMPT.

Form 543

DMRTI JOP Student Nomination

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

AFHSB 501 Request Form

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form

DHA-GL Worksheet 41: DoD/VA MOA Inpatient-Outpatient Continued Stay Review

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

EACE Data Request Form

Form for users to fill out to request information/data from EACE

DHA-GL Worksheet : Discharge Summary

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 VAMC Richmond Only

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

Data Sharing Agreement (DSA) - Renewal Request Template 2019.10.28

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