TRICARE West Region Beneficiary Forms

Welcome TRICARE West Region beneficiaries! Here you will find a variety of forms you may need to manage your health care. You can download and print these forms. If you need an online version, please log into the secure, self-service beneficiary portal.

Claims

• Other Health Insurance (OHI) Questionnaire
• Appointment of Representative

Enrollment and Billing

• Automatic Monthly TRICARE Payment Set Up Request
• Start, Change or Stop Your Allotment
• TRICARE Prime/Select/Reserve Recurring Credit Card/Electronic Funds Transfer payment (start or change request)
• TRICARE Young Adult Recurring Credit Card/Electronic Funds Transfer (start or change request)
• Enrollment Reconsideration Request (coming soon!)

Enrollment Forms

• TRICARE Prime, Prime Remote, Prime Overseas, Prime Remote Overseas (DD 2876-2)
• TRICARE Select, Select Overseas (DD 3043-2)
• TRICARE Young Adult (DD 2947-2)

Customer Service

• Authorization to Disclose
• West Region Grievance

HIPAA/Privacy

• HIPAA Disclosure Accounting Request
• HIPAA Privacy Complaint Form
• HIPAA Request for Records
• HIPAA Request to Amend Personal Health Information
• HIPAA Restriction Request
• Request for Confidential Communications