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.
- National Provider Identifier (NPI) Form
- 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 Prescriptions 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
- Request for Reimbursement of TRICARE Hospice Cap Amount
- Timely Filing Waiver
- TRICARE Non-Network Autism Care Demonstration (ACD) (BCBA, BCBA-D and LBA) Individual Application
- Non-network TRICARE Provider File Group Application
- Appeals Forms
- Freestanding Psychiatric and Substance Use Disorder (SUD) Partial Hospitalization Program (PHP) Provider Application
- Institutional Provider Application
- Inpatient/Residential Substance Use Disorder Rehabilitation Facility (SUDRF) Provider Application
- Institutional Intensive Outpatient Program (IOP) Provider Application
- Institutional Opioid Treatment Program (OTP) Provider Application
- Institutional Residential Treatment Center (RTC) Provider Application
- Autism Care Demonstration (ACD) Board Certified Behavior Analyst (BCBA/BCBA-D) and Licensed Behavior Analyst (LBA) Provider Application
- Austism Care Demonstration Corporate Service Provider (ACSP) Provider Application
- Ambulance Application
- Anesthesiologist Assistant (AA) Provider Application
- Birthing Center Application
- Certified Marriage and Family Therapist Provider Application
- Certified Nurse Midwife (CNM) Provider Application
- Certified Registered Nurse Anesthetist (CRNA) Provider Application
- Christian Science Practitioner or Christian Science Nurse Provider Application
- Clinical Psychologist Provider Application
- Clinical Social Worker Provider Application
- Corporate Services Provider
- Donor Milk Bank Supplier Application
- Equipment Supplier Application
- Home Health Agency Provider Application
- Hospice Provider Application
- Laboratory Application
- Lactation Consultant (LC) Certified Lactation Counselor (CLC) Certified Labor Doula(CLD)
- Mental Health Counselor (SMHC/TCMHC) Provider Application
- Nutritionist Provider Application
- Pastoral Counselor Provider Application
- Psychiatric Nurse Specialist Provider Application
- Physical Therapist Assistant (PTA)/Occupational Therapy Assistant (OTA) Provider Application
- Physical Therapist/Speech Therapist/Occupational Therapist/Audiologist Provider Application
- Physician Assistant Provider Application
- Physician/Dentist Provider Application
- Portable X-Ray or Mammography Supplier Application
- Provider's Notarized Facsimile or Stamp Signature Authorization
- Registered Dietitian Provider Application
- Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Nurse Practitioner (NP) Provider Application
- Skilled Nursing Facility Provider Application
- State Vaccine Program Supplier Application
- Instructions for Completing the TRICARE West NPI Form
- Practitioner Affiliation/Disaffiliation Request Form
- Provider Autism Care Demonstration Basic life Support (BLS)/CPR Requirement Form
- Provider Information Update Request Form
- Provider Specialty Information Update Request Form
- UB-04 "Signature on File" for TRICARE Claims Form
Online referrals/auths are 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.