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

• Claims Reconsideration
• Certificate of Medical Necessity
• EDI Gateway Technical Communications User's Manual
• EDI Provider Trading Partner Agreement
• Electronic Funds Transfer (EFT) & Electronic Remittance Advice (ERA) Enrollment Package
• Recoupment Request
• Timely Filing Waiver
• Request for Non-covered Services

Clinical Care

• TRICARE Clinical Care Support Program Referral Form

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

NOTE: A Primary Care Manager Referral Waiver is in place Jan. 1 - April 30, 2025.

Online referrals/auths is the fastest way to process care requests for your TRICARE patients. Read the referral/authorization guidelines to learn more.

Already submitted via fax? Consider resubmitting online for faster response times.

• TRICARE West Region Referral/Authorization Form
  NOTE: For fastest processing time and optimal results, please complete the form by filling out the PDF fields rather than hand writing.

Participation Agreements

• Autism Care Demonstration Program
• Birthing Center / Maternity Care Services
• Certified Labor Doulas
• Hospice Program
• Intensive Outpatient
• Marriage and Family Therapist
• Opioid Treatment Program
• Residential Treatment Center
• Substance Use Disorder Residential Facility