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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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Smallpox Vaccine Screening or Medical Note Continuation Page

Form/Template
2/7/2008

This form is used to identify additional Notes on Problems, Issues or Concerns of Patient or Provider related to Vaccine Assessment or Follow-up.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

CMS-1450 UB-04 Uniform Bill

Form/Template
3/1/2007

Form and CMS 1450 Data Set Medicare Claim Processing Manual Instructions for Institutional Services

Recommended Content:

Health Plan and Policy Billing Guidelines

DD Form 2802: Report of Medical Examination

Form/Template
1/10/2005

To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.

Recommended Content:

Medical Evaluation Board | Physical Evaluation Board

OIF DU Exposure Semi-Annual Progress Report

Form/Template
9/30/2004

This form is used to record DU Bioassay/Fragment Testing and Results Information

Depleted Uranium Questionnaire

Form/Template
2/1/2004

This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care.

Recommended Content:

DU Medical Follow-Up Program

Health Survey, DD Form 2872-1 Test

Form/Template
2/1/2004

This form is used to assess your state of health after deployment or for any deployment related concern and to assist military health care providers in identifying and providing present and future medical care to you.

DD Form 2871: Request to Restrict Medical or Dental Information Form

Form/Template
12/1/2003

This form is to provide the patient with a means to request a restriction on the use and disclosure of his/her protected health information.

Recommended Content:

How HIPAA Protects You

DD Form 2870: Authorization for Disclosure of Medical or Dental Information Form

Form/Template
12/1/2003

This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.

Recommended Content:

How HIPAA Protects You

Third Party Collections Program - Report on Program Results

Form/Template
6/1/2001

Use this form to submit your Third Party Collections Program reports.

Recommended Content:

Performance Measurements | Third Party Collection Program
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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