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TriWest Healthcare Alliance Recognized for Call Center Customer Satisfaction Excellence
TriWest Healthcare’s Call Center has been recognized by J.D. Power and Associates for providing “An Outstanding Customer Service Experience”
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For J.D. Power and Associates 2010 Call Center Certification ProgramSM information, visit www.jdpower.com
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Enrollment Forms
Form Name PDF Fill &
Print 		Online PDF Revision
Continued Health Care Benefits Program Enrollment Form (CHCBP)
( DoD Form: 2837 ) 		Continued Health Care Benefits Program Enrollment Form (CHCBP) Continued Health Care Benefits Program Enrollment Form (CHCBP) Continued Health Care Benefits Program Enrollment Form (CHCBP) 05/2010
TRICARE Prime Disenrollment Application
( DoD Form: 2877 ) 		TRICARE Prime Disenrollment Application TRICARE Prime Disenrollment Application TRICARE Prime Disenrollment Application 04/2007
TRICARE Prime Enrollment Application & PCM Change Form
( DoD Form: 2876 ) 		TRICARE Prime Enrollment Application & PCM Change Form TRICARE Prime Enrollment Application & PCM Change Form TRICARE Prime Enrollment Application & PCM Change Form 04/2007
TRICARE Reserve Select (TRS) Information Update Form
( FR530002BEAL0707 ) 		TRICARE Reserve Select (TRS) Information Update Form TRICARE Reserve Select (TRS) Information Update Form TRICARE Reserve Select (TRS) Information Update Form 03/2010

Fee Payments
Form Name PDF Fill &
Print 		Online PDF Revision
Allotment Authorization Letter – TRICARE Prime
( FM533BEW07084 ) 		Allotment Authorization Letter – TRICARE Prime Allotment Authorization Letter – TRICARE Prime Allotment Authorization Letter – TRICARE Prime 07/2008
Electronic Payment Authorization Form - TRICARE Prime
( 2010288FR ) 		Electronic Payment Authorization Form - TRICARE Prime Electronic Payment Authorization Form - TRICARE Prime Electronic Payment Authorization Form - TRICARE Prime 07/2010
Electronic Payment Authorization Form - TRICARE Reserve Select (TRS)
( 2010289FR ) 		Electronic Payment Authorization Form - TRICARE Reserve Select (TRS) Electronic Payment Authorization Form - TRICARE Reserve Select (TRS) Electronic Payment Authorization Form - TRICARE Reserve Select (TRS) 07/2010
Enrollment Fee Refund Request – TRICARE Prime and TRS
( FR900005BEAL0107 ) 		Enrollment Fee Refund Request – TRICARE Prime and TRS Enrollment Fee Refund Request – TRICARE Prime and TRS Enrollment Fee Refund Request – TRICARE Prime and TRS 01/2008

Health Insurance Portability and Accountability Act (HIPAA)
Form Name PDF Fill &
Print 		Online PDF Revision
Authorization to Disclose Form
( FR910012BEAL0408 ) 		Authorization to Disclose Form Authorization to Disclose Form Authorization to Disclose Form 04/2010
HIPAA Access Request Form
( FR911005BEAL0904 ) 		HIPAA Access Request Form HIPAA Access Request Form HIPAA Access Request Form 04/2010
HIPAA Amendment Request Form
( FR911006BEAL0904 ) 		HIPAA Amendment Request Form HIPAA Amendment Request Form HIPAA Amendment Request Form 04/2010
HIPAA Complaint Form
( FR911004BEAL0904 ) 		HIPAA Complaint Form HIPAA Complaint Form HIPAA Complaint Form 04/2010
HIPAA Confidential Communication Form
( FR911002BEAL0704 ) 		HIPAA Confidential Communication Form HIPAA Confidential Communication Form HIPAA Confidential Communication Form 04/2010
HIPAA Disclosure Accounting Request
( FR911007BEAL0904 ) 		HIPAA Disclosure Accounting Request HIPAA Disclosure Accounting Request HIPAA Disclosure Accounting Request 04/2010
HIPAA Restriction Request
( FR911003BEAL0704 ) 		HIPAA Restriction Request HIPAA Restriction Request HIPAA Restriction Request 04/2010

Claims
Form Name PDF Fill &
Print 		Online PDF Revision
Appointment of Representative for Appeal
( 2010-165-FR ) 		Appointment of Representative for Appeal Appointment of Representative for Appeal Appointment of Representative for Appeal 03/2010
Beneficiary Claim Form
( DoD Form: 2642 ) 		Beneficiary Claim Form Beneficiary Claim Form Beneficiary Claim Form 04/2007
Other Health Insurance Form (OHI)
( FM521BEW10074 ) 		Other Health Insurance Form (OHI) Other Health Insurance Form (OHI) Other Health Insurance Form (OHI) 10/2007
Third Party Liability
( DoD Form: 2527 ) 		Third Party Liability Third Party Liability Third Party Liability 01/2008
Waiver of Non-Covered Services
( FR440017PRAL0107 ) 		Waiver of Non-Covered Services Waiver of Non-Covered Services Waiver of Non-Covered Services 01/2007

Spanish Forms
Form Name PDF Fill &
Print 		Online PDF Revision
Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI)
( FM591BEW01084SP ) 		Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI) Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI) Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI) 10/2007
Letra De la Autorización De la Asignación Del Honorario De la Inscripción
( FM561BEW02084SP ) 		Letra De la Autorización De la Asignación Del Honorario De la Inscripción Letra De la Autorización De la Asignación Del Honorario De la Inscripción Letra De la Autorización De la Asignación Del Honorario De la Inscripción 02/2008