Tricare Medical Form



Tricare medical form can be filled by personnel serving in the US Army, Navy, and Air Force as well as retired US military service members and their families living anywhere in the world. Tricare is a medical insurance company that offers several affordable health plans including dental options to members and retirees of seven different uniformed services in the US. The Tricare medical form is required to be filled when applying for enrollment into the Tricare medical program.

You can Download the Free Tricare Medical Form, customize it according to your needs and Print. Tricare Medical Form is either in MS Word, Excel or in PDF.

Sample Tricare Medical Form

Tricare Medical Form

Download TRICARE Medical Necessity Form

TRICARE Medical Necessity Form

This form applies to the TRICARE Medical Program. The medical program criteria outlined in this form also applies to the Military Treatment Facilities (MTFs). This form must be completed and signed by the patient or applicant.
Step 1 Please complete patient and physician information (please print):
Name of the patient Physician’s Name
Address

 

 

City/State/Zip

Address

 

 

City/State/Zip

Phone Phone
Sponsor ID# Fax
Date of Birth  
Please Do Not Return Your Form To The Above Organization. Return Completed Form To The Following Servicing Contractor:

Health Net Federal Services, LLC

P.O. Box 105402

Atlanta, GA 30348-5402

Privacy Act Statement

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. Chapter 17, Hospital, Nursing Home, Domiciliary, and Medical Care; 32 CFR Part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.
DISCLOSURE: Voluntary; however, failure to furnish all requested information may result in denial of the individual’s purchase, transfer, or termination of TRICARE Adult Program health plan coverage.
TRICARE COVERAGE DESIRED (X one. Based on Uniformed Service sponsor’s status.)
TRICARE Prime (where available and if qualified) TRICARE Standard

 

TRICARE Overseas Prime (dependent must be command sponsored and meet specific enrollment criteria of the overseas area) TRICARE Reserve Select (sponsor must be enrolled in TRS)
TRICARE Retired Reserve (sponsor must be enrolled in TRR)

 

TRICARE Prime Remote for Active Duty Family Members

(sponsor must be enrolled in TPR)

 

Uniformed Services Family Health Plan (where available and if

qualified)

 
MEDICAL INFORMATION OF THE APPLICANT
Immunizations till date

 

Blood Pressure
Allergies (if any) Blood Sugar

 

Cholesterol Hepatic Medical Condition

 

Respiratory Condition

 

Cardiac Condition
Infections (Ear, Nose, others)

 

 
I certify that the above information is true and correct to the best of my knowledge
 

…………………………………….

Signature of the Applicant                                                                    Date

Category: Medical Forms

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