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Beneficiary Forms
Enrollment
Continued Health Care Benefit Program Enrollment Form
Prime Disenrollment Application Form
Prime Enrollment/PCM Change Form
Extended Care Health Option (ECHO) Application
Enrollment Related
Allotment Authorization Letter
Autorización para Asignación de Cuotas de Inscripción
Electronic Funds Transfer Authorization Form (EFT) - Prime
Electronic Funds Transfer Authorization Form (EFT) - TRICARE Reserve Select
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)
Request for Retroactive Enrollment Form
TRICARE Reserve Select (TRS) Reconsideration Request Form
TRICARE Reserve Select (TRS) Auto Charge Request Form
TRICARE Retired Reserve (TRR) Auto Charge Form
TRICARE Retired Reserve (TRR) Electronic Fee Transfer Form
TRICARE Retired Reserve (TRR) Reinstatement Request 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
Last Update: August 27, 2010
