Portal HomeAccess to Tricare
bottom stripe
TriWest Healthcare Alliance Recognized for Call Center Customer Satisfaction Excellence
About TriWest   |    Employment   |    Contact Us   |    Site Map   |   News Room
URAC
Quick Links
Provider Forms
Claims/Reimbursement
Referrals/Auths
Patient Eligibility
Policy Updates
Provider Handbook
Prior Authorization List
 

Your opinion is important to us! Let us know how we're doing.
Tab Background
Decrease Font Size Default Font Size Increase Font Size Send this Page Via Email Print this Page

General
Form Name File Type Fill & Print Revision
An Important Message from TRICARE An Important Message from TRICARE An Important Message from TRICARE 02/2008
An Important Message from TRICARE (Spanish) An Important Message from TRICARE (Spanish) An Important Message from TRICARE (Spanish) 01/2009
Electronic Remittance Advice Electronic Remittance Advice Electronic Remittance Advice 05/2009
Explanation of Benefits -- Sample Explanation of Benefits -- Sample Explanation of Benefits -- Sample 02/2009
Other Health Insurance Form (OHI) Other Health Insurance Form (OHI) Other Health Insurance Form (OHI) 01/2007
Other Health Insurance Form (OHI) (Spanish) Other Health Insurance Form (OHI) (Spanish) Other Health Insurance Form (OHI) (Spanish) 01/2005
Third Party Liability Form Third Party Liability Form Third Party Liability Form 10/2004
TriWest Provider EDI Agreement Form TriWest Provider EDI Agreement Form TriWest Provider EDI Agreement Form 11/2008
Waiver of Non-Covered Services Waiver of Non-Covered Services Waiver of Non-Covered Services 01/2007
Waiver of Non-Covered Services - Sample Waiver of Non-Covered Services - Sample Waiver of Non-Covered Services - Sample 01/2008

Medical/Surgical Referral/Authorization
Form Name File Type Fill & Print Revision
TRICARE Patient Referral/Authorization Form You can now submit a ref/auth online. Register on triwest.com today! You can now submit a ref/auth online. Register on triwest.com today! 04/2009
TRICARE Patient Referral/Authorization Form - Sample You can now submit a ref/auth online. Register on triwest.com today! You can now submit a ref/auth online. Register on triwest.com today! 10/2008

Behavioral Health
Form Name File Type Fill & Print Revision
Inpatient Emergency Admission - Detox Inpatient Emergency Admission - Detox Inpatient Emergency Admission - Detox 01/2008
Inpatient Emergency Admission - Mental Health Inpatient Emergency Admission - Mental Health Inpatient Emergency Admission - Mental Health 01/2008
PCM Communication Form PCM Communication Form PCM Communication Form 03/2007
Preauthorization for Electroconvulsive Therapy (ECT) Preauthorization for Electroconvulsive Therapy (ECT) Preauthorization for Electroconvulsive Therapy (ECT) 01/2007
Preauthorization for Inpatient Substance Abuse Rehabilitation Preauthorization for Inpatient Substance Abuse Rehabilitation Preauthorization for Inpatient Substance Abuse Rehabilitation 01/2008
Preauthorization for Outpatient Treatment Request Preauthorization for Outpatient Treatment Request Preauthorization for Outpatient Treatment Request 01/2008
Preauthorization for Outpatient Treatment Request - Sample Preauthorization for Outpatient Treatment Request - Sample Preauthorization for Outpatient Treatment Request - Sample 09/2008
Preauthorization for Partial Hospitalization Preauthorization for Partial Hospitalization Preauthorization for Partial Hospitalization 01/2008
Preauthorization for Psychological/Neuropsychological Testing Preauthorization for Psychological/Neuropsychological Testing Preauthorization for Psychological/Neuropsychological Testing 12/2008
Residential Treatment Center (RTC) Application Residential Treatment Center (RTC) Application Residential Treatment Center (RTC) Application 01/2008

Certification
Form Name File Type Fill & Print Revision
Allied Provider Certification Allied Provider Certification Allied Provider Certification 12/2006
Ambulance Certification Ambulance Certification Ambulance Certification 12/2006
Autism Provider Certification Application Autism Provider Certification Application Autism Provider Certification Application 04/2008
Certified Nurse Midwife Certification Certified Nurse Midwife Certification Certified Nurse Midwife Certification 12/2006
Certified Psych Nurse Specialist Certification Certified Psych Nurse Specialist Certification Certified Psych Nurse Specialist Certification 12/2006
Clinic or Group Practice Certification Clinic or Group Practice Certification Clinic or Group Practice Certification 12/2006
Clinical Psychologist Certification Clinical Psychologist Certification Clinical Psychologist Certification 12/2006
Clinical Social Worker Certification Clinical Social Worker Certification Clinical Social Worker Certification 12/2006
DME Certification DME Certification DME Certification 12/2006
Home Health Certification Home Health Certification Home Health Certification 12/2006
Independent Lab Certification Independent Lab Certification Independent Lab Certification 01/2007
Individual Physician Certification Individual Physician Certification Individual Physician Certification 12/2006
Institutional Certification Institutional Certification Institutional Certification 12/2006
Marriage and Family Therapist Certification Marriage and Family Therapist Certification Marriage and Family Therapist Certification 12/2006
Mental Health Counselor Certification Mental Health Counselor Certification Mental Health Counselor Certification 12/2006
Pastoral Counselor Certification Pastoral Counselor Certification Pastoral Counselor Certification 12/2006
Pharmacy Non-Retail Certification Pharmacy Non-Retail Certification Pharmacy Non-Retail Certification 12/2006
Physician Assistant Certification Physician Assistant Certification Physician Assistant Certification 12/2006
Physiological Lab Certification Physiological Lab Certification Physiological Lab Certification 12/2006
Skilled Nursing Facility Certification Skilled Nursing Facility Certification Skilled Nursing Facility Certification 12/2006

Clinical Programs
Form Name File Type Fill & Print Revision
Applied Behavioral Analysis Applied Behavioral Analysis Applied Behavioral Analysis 10/2005
Cancer Clinical Trials Patient Authorization Form Cancer Clinical Trials Patient Authorization Form Cancer Clinical Trials Patient Authorization Form 04/2008
Case Management Referral Form Case Management Referral Form Case Management Referral Form 01/2009
ECHO and Autism Patient Referral Form ECHO and Autism Patient Referral Form ECHO and Autism Patient Referral Form 01/2009
Hospice Authorization Form Hospice Authorization Form Hospice Authorization Form 04/2009
Participation Agreement for Hospice Program Services Participation Agreement for Hospice Program Services Participation Agreement for Hospice Program Services 05/2009
Qualifying Condition Determination for ECHO-Referral Qualifying Condition Determination for ECHO-Referral Qualifying Condition Determination for ECHO-Referral 01/2005
Quality Management (QM) Potential Quality Issue (PQI) Referral Quality Management (QM) Potential Quality Issue (PQI) Referral Quality Management (QM) Potential Quality Issue (PQI) Referral 05/2004
Referral for TRICARE 1:1:1 Program Referral for TRICARE 1:1:1 Program Referral for TRICARE 1:1:1 Program 06/2008
TBI Program Referral Form TBI Program Referral Form TBI Program Referral Form 04/2009

Clinical Information
Dental File Type Fill & Print Revision
Hospital Charges for Non-Adjunctive Dental Care Hospital Charges for Non-Adjunctive Dental Care Hospital Charges for Non-Adjunctive Dental Care 01/2008
Iatrogenic Dental Trauma Treatment Iatrogenic Dental Trauma Treatment Iatrogenic Dental Trauma Treatment 01/2008
Oral Surgery/Orthodontia Oral Surgery/Orthodontia Oral Surgery/Orthodontia 02/2009
Temporomandibular Joint Dysfunction Treatment Temporomandibular Joint Dysfunction Treatment Temporomandibular Joint Dysfunction Treatment 01/2008
 
Injectable Medications      
Injectable Medications Injectable Medications Injectable Medications 01/2008
Synagis Synagis Synagis 01/2008
Xolair Xolair Xolair 01/2008
 
Medical Equipment/Supplies      
C-leg Microprocessor Lower Limb Prosthesis C-leg Microprocessor Lower Limb Prosthesis C-leg Microprocessor Lower Limb Prosthesis 01/2008
Insulin Pump Insulin Pump Insulin Pump 01/2008
Wheeled Mobility Wheeled Mobility Wheeled Mobility 01/2008
 
Therapies      
Nutritional Therapy Nutritional Therapy Nutritional Therapy 01/2008