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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.

TRICARE Retail Refund Appendix A Change Request Form

Form/Template
11/6/2018

Use this form to add/delete/transfer or make changes to your current Appendix A

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
10/23/2018

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

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/21/2018

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
8/21/2018

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Potentially Compromised Temperature Sensitive Medical Products (PC TSMP) Worksheet

Form/Template
8/1/2018

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

PC TSMP Worksheet (Continuation Sheet)

Form/Template
8/1/2018

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

OIG DD2949 Whistleblower Complaint Form

Form/Template
7/26/2018

This is a form that users will download and either FAX or mail to file a complaint to the DHA IG office.

Freezer Temperature Log - Celsius

Form/Template
7/12/2018

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Fahrenheit

Form/Template
7/12/2018

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
7/11/2018

Monitoring the temperature of your vaccine storage unit is required at least twice a day, and should be logged using this form.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Celsius

Form/Template
7/11/2018

Temperature log for refrigerators storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Emergency Vaccine Retrieval and Storage Plan Worksheet

Form/Template
7/10/2018

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

PIA Navy Medicine Online

Form/Template
6/8/2018

This Privacy Impact Assessment is from Navy Medicine Online. The Navy Medicine Online (NMO) serves a vital role in the overall process of collecting, analyzing, and brokering medical readiness data to and from critical and authoritative Department of Defense (DoD) data sources into one common operational view that can be drilled down into individual ...

DHA-GL Worksheet-02: Pre-Authorization Request

Form/Template
5/31/2018

Defense Health Agency - Great Lakes Worksheet (DAH-GL Worksheet-02) This worksheet is used to request pre-authorization for medical care for Reserve Component Members

TRICARE Online (TOL)

Form/Template
5/21/2018

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the TRICARE Online (TOL) system.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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