TRICARE West Region Provider Forms
Welcome TRICARE West Region providers! Here you will find a variety of forms you may need to manage your patients’ health care. You can download and print these forms.
Claims
- Breast Pump Prescription Form
- Capital and Direct Medical Education Costs Reimbursement
- Claims Reconsideration
- Certificate of Medical Necessity
- Cover Sheet for submitting Medical Records to PGBA
- Cover Sheet for submitting Certificate of Medical Necessity/Prescription for DME denials to PGBA
- EDI Gateway Technical Communications User's Manual
- EDI Provider Trading Partner Agreement
- Electronic Funds Transfer (EFT) & Electronic Remittance Advice (ERA) Enrollment Package
- Recoupment Request
- Request for Non-covered Services
- Timely Filing Waiver
Clinical Care
Customer Service
Non-Network Provider Application
- TRICARE Non-Network Autism Care Demonstration (ACD) (BCBA, BCBA-D and LBA) Individual Application
- Non-network TRICARE Provider File Group Application
Referrals and Authorizations
Online referrals/auths is the fastest way to process care requests for your TRICARE patients. Read the referral/authorization guidelines to learn more. If you have issues submitting your referral or authorization using the online referral management system, please use the Alternative Referral and Authorization Form available on Availity. For more information, view the Alternative Referral and Authorization Form Quick Reference Guide.
Already submitted via fax? Consider resubmitting online for faster response times.
- TRICARE West Region Referral/Authorization Form
NOTE: Use of this fax form should be limited. Please ensure you have read the West Region referral/authorization guidelines before submitting.