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Beneficiary Services
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Enrollment Forms
Form Name
PDF
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PDF Revision
Continued Health Care Benefits Program Enrollment Form (CHCBP)
( DoD Form: 2837 )
09/2006
TRICARE Prime Disenrollment Application
( DoD Form: 2877 )
04/2007
TRICARE Prime Enrollment Application & PCM Change Form
( DoD Form: 2876 )
04/2007
TRICARE Reserve Select (TRS) Information Update Form
( FR530002BEAL0707 )
04/2005
Fee Payments
Form Name
PDF
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PDF Revision
Allotment Authorization Letter – TRICARE Prime
( FM533BEW07084 )
07/2008
Electronic Payment Authorization Form - TRICARE Prime
( FR800009BEAL0408 )
04/2008
Electronic Payment Authorization Form - TRICARE Reserve Select (TRS)
( FR800010BEAL1208 )
12/2008
Enrollment Fee Refund Request – TRICARE Prime and TRS
( FR900005BEAL0107 )
01/2008
Health Insurance Portability and Accountability Act (HIPAA)
Form Name
PDF
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PDF Revision
Authorization to Disclose Form
( FR910012BEAL0408 )
04/2008
HIPAA Access Request Form
( FR911005BEAL0904 )
09/2004
HIPAA Amendment Request Form
( FR911006BEAL0904 )
04/2004
HIPAA Complaint Form
( FR911004BEAL0904 )
09/2004
HIPAA Confidential Communication Form
( FR911002BEAL0704 )
07/2004
HIPAA Disclosure Accounting Request
( FR911007BEAL0904 )
09/2004
HIPAA Restriction Request
( FR911003BEAL0704 )
07/2004
Claims
Form Name
PDF
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PDF Revision
Appointment of Representative for Appeal
( FR920001BEAL1008 )
10/2008
Beneficiary Claim Form
( DoD Form: 2642 )
04/2007
Other Health Insurance Form (OHI)
( FR901003BEAL0107 )
01/2007
Third Party Liability
( DoD Form: 2527 )
01/2008
Waiver of Non-Covered Services
( FR440017PRAL0107 )
01/2007
Spanish Forms
Form Name
PDF
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Print
Online
PDF Revision
Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI)
( FM591BEW01084SP )
01/2008
Letra De la Autorización De la Asignación Del Honorario De la Inscripción
( FM561BEW02084SP )
02/2008