Back to Top Skip to main content

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.

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 ...

AHLTA

Form/Template
5/21/2018

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the AHLTA system.

Dental Common Access System

Form/Template
5/21/2018

Dental Common Access System (DENCAS)

TRICARE Online (TOL)

Form/Template
5/21/2018

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

Veterinary Services Systems Management

Form/Template
5/21/2018

Veterinary Services Systems Management (VSSM)

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
5/16/2018

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

PC TSMP Worksheet Continuation Sheet

Form/Template
5/15/2018

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

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
5/16/2018

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

PC TSMP Worksheet

Form/Template
5/15/2018

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

Epidemiology and Analysis Data Request Approval Process (RAP) Form

Form/Template
5/3/2018

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis Data Request Approval Process (RAP) Form

Request for DoD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary

Form/Template
2/28/2018

Please attach MTF P&T Committee comments & meeting minutes, an explanation of the rationale for the request, copies of supporting clinical evidence, and anything else that needs to be considered by the DoD P&T Committee.

Recommended Content:

TRICARE Formulary

UF BCF ECF OTC Request Form Feb 2018

Form/Template
2/26/2018

MTF Drug Request Review Form

PDTS Data Report Request Form

Form/Template
2/13/2018

The PDTS reports function is constantly evolving and as we continue to find new applications for the data collected by PDTS, the reports function will be modified to meet those demands.

PDTS Report Request Form

Form/Template
2/13/2018

This form is used to assist providers in the identification of patients who have received prescriptions for controlled substances over a given period of time and provide them with an automated process to analyze the data.

Program Integrity Report Request Form

Form/Template
2/13/2018

This form is designed to accommodate requests for patient, drug, provider, and pharmacy profiles. If you need assistance completing this form please call the number shown above. The PASS cannot act on any report request until the form has been approved and the requestor has agreed with the method of extract and the structure of the report.

<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 20

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

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing: Download a PDF Reader or learn more about PDFs.