Humana-Military.com

Beneficiary Forms


Enrollment
Continued Health Care Benefit Program Enrollment Form  
Prime Disenrollment Application Form  
Prime Enrollment/PCM Change Form  
 
For enrollment or PCM changes in TRICARE Prime/TRICARE Prime Remote, submit the completed Application/PCM Change Form to the address below:
 
Humana Military Healthcare Services
Attn. PNC Bank
P.O. Box 105838
Atlanta, GA 30348-5838

Fax number:  866-836-9535
  
Extended Care Health Option (ECHO) Application 
TRICARE Young Adult Program Application 

Enrollment Related
Allotment Authorization Letter    
Autorización para Asignación de Cuotas de Inscripción  Spanish 
Auto Charge Request Form - TRICARE Reserve Select
Auto Charge Request Form - TRICARE Retired Reserve
Auto Charge Request Form - TRICARE Young Adult
Electronic Funds Transfer Authorization Form (EFT) - Prime 
Electronic Funds Transfer Authorization Form (EFT) - TRICARE Reserve Select 
Electronic Funds Transfer Authorization Form (EFT) - TRICARE Retired Reserve  
Electronic Funds Transfer Authorization Form (EFT) - TRICARE Young Adult  
Lockout Waiver Request Form 
Newborn/Adoptee Waiver Request Form 
Other Health Insurance Coverage Questionnaire  
Cuestionario de TRICARE Sobre la Cobertura de Otro Seguro Medico (OHI) Spanish 
Reinstatement Request Form - TRICARE Reserve Select
Reinstatement Request Form - TRICARE Retired Reserve
Reinstatement Request Form - TRICARE Young Adult
Request for Retroactive Enrollment Form   

HIPAA
Authorization for Release of Information Form - General   
Authorization for Release of Information Form - Sensitive Diagnosis   
Revocation of Authorization  

Claims
Appointment of Representative   
Claim Form (DD2642)  
Public Facility Use Certification Form    
Third Party Liability Claim Form    

Related Links
TRICARE Prime Travel Benefit Program 
TRICARE Forms 
All files are posted as PDFs unless otherwise noted.
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Last Update: January 18, 2012