TRICARE Beneficiaries: Forms

Forms

Find the form you need from the categories listed below. Here, you'll find claim, enrollment and disenrollment forms--some are found on external sites.

To download PDF forms, you need Acrobat Reader which can be downloaded for free.

Claim Forms
Dental Forms
Enrollment/Disenrollment Forms
Pharmacy Forms
More Forms

Claim Forms

TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)

Statement of Personal Injury-Possible Third Party Liability (DD Form 2527)

TRICARE Active Duty Dental Claim Form

TRICARE Dental Program

For Dental Care Received through April 30, 2012:

You'll file claims with United Concordia. Claims will be accepted for up to one year after the date of service (through April 30, 2013).

United States Claim Form
Overseas Claim Form

For Dental Care Received beginning May 1, 2012:

You'll file claims with MetLife. Visit https://mybenefits.metlife.com/tricare to download claim submission documents and instructions.

TRICARE Retiree Dental Program Claim Form (United States)

TRICARE Retiree Dental Program Overseas Claim Form (Overseas)

Dental Forms

TRICARE Active Duty Dental Program Forms

TRICARE Dental Program Forms

TRICARE Retiree Dental Program Forms

Enrollment/Disenrollment Forms

TRICARE Prime/Prime Remote Enrollments

North Region - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876)

South Region - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876)

West Region - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876)

Mail this completed application to your regional contractor at the following addresses:

North	South	West
Health Net Federal Services, LLC P.O. Box 105146 Atlanta, GA, 30348-5146	Humana Military Healthcare Services, Inc. Attn: PNC Bank P.O. Box 105838 Atlanta, GA 30548-9758	TriWest Healthcare Alliance P.O. Box 43590 Phoenix, AZ 85080-3590

TRICARE Prime Overseas/TRICARE Prime Remote Overseas

TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876)

Submit your completed enrollment application along with a copy of your orders to your regional call center or a TRICARE Service Center. Or mail your completed enrollment form to:

International SOS Assistance
TOP Prime Enrollments
P.O. Box 11520
Philadelphia, PA 19116

TRICARE Prime Disenrollment Request

TRICARE Prime Disenrollment Request (DD Form 2877)

TRICARE Reserve Select

DMDC Reserve Component Purchased TRICARE Application

To log on, you must have one of the following:

The DS Logon Premium (Level 2) account is given to a user who has registered using their CAC, DFAS myPay Login ID, or has a DS Logon Basic Account. Click here to sign up or view information regarding a DS Logon .

TRICARE Retired Reserve

DMDC Reserve Component Purchased TRICARE Application

To log on, you must have one of the following:

TRICARE Young Adult

North Region - TRICARE Young Adult Application (DD Form 2947) South Region - TRICARE Young Adult Application (DD Form 2947) West Region - TRICARE Young Adult Application (DD Form 2947) Overseas - TRICARE Young Adult Application (DD Form 2947)

If you select the US Family Health Plan as your Prime Option, please use one of the forms listed below:

Johns Hopkins - TRICARE Young Adult Application (DD Form 2947)Martin's Point - TRICARE Young Adult Application (DD Form 2947)Brighton Marine - TRICARE Young Adult Application (DD Form 2947)St. Vincent - TRICARE Young Adult Application (DD Form 2947)CHRISTUS - TRICARE Young Adult Application (DDD Form 2947)PacMed Centers - TRICARE Young Adult Application (DD Form 2947)

Submit the application to the address listed on the back of the form. If you're not sure which region you live in, click here for a list of states/countries in each region.

US Family Health Plan

Johns Hopkins - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876)
Martin's Point - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876) Brighton Marine - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876) St. Vincent - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876) CHRISTUS - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876) PacMed Centers - TRICARE Prime Enrollment Application and PCM Change Form (DD Form 2876

Mail this completed application to your Designated Provider at the following addresses:

Johns Hopkins	US Family Health Plan at Johns Hopkins P.O. Box 815 Glen Burnie, MD 21060
Martin's Point Health Care	US Family Health Plan at Martin's Point Health Care P.O. Box 9746 Portland, ME 04104
Brighton Marine Health Center	US Family Health Plan at Brighton Marine P.O. Box 9195 Watertown, MA 02471
St. Vincent Catholic Medical Centers	US Family Health Plan at St. Vincent NYC 450 W. 33rd Street, Mezzanine New York, NY 10001
CHRISTUS Health	US Family Health Plan at CHRISTUS Health P.O. Box 924708 Houston, TX 77292
Pacific Medical Centers	US Family Health at Pacific Medical Centers P.O. Box 84985 Seattle, WA 98124

Continued Health Care Benefit Program

Continued Health Care Benefit Program Enrollment Application (DD Form 2837)

Pharmacy Forms

TRICARE Home Delivery Pharmacy Registration Form

Medical Necessity Forms

Prior Authorization Forms

More Forms

Application for Identification Card/DEERS Enrollment (DD Form 1172-2)

North Region Forms

Go to this page for North region-specific forms such as enrollment fee payment forms, appeals & grievance, HIPAA/privacy forms and other health insurance questionnaires.

South Region Forms

Go to this page for South region-specific forms such as enrollment fee payment forms, appeals & grievance, HIPAA/privacy forms and other health insurance questionnaires.

West Region Forms

Go to this page for West region-specific forms such as enrollment fee payment forms, appeals & grievance, HIPAA/privacy forms and other health insurance questionnaires.

Overseas Forms

Go to this page for Overseas-specific forms such as enrollment fee payment forms, HIPAA/privacy forms and other health insurance questionnaires.

WPS-TRICARE For Life Forms

Go to this page for forms used by the TRICARE For Life contractor such as HIPAA/privacy forms and other health insurance questionnaires.

TRICARE, Your Military Health Plan

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