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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 Health Allied Health Allied Health 09/2009
Ambulance Ambulance Ambulance 08/2009
Ambulatory Surgical Centers Ambulatory Surgical Centers Ambulatory Surgical Centers 08/2009
Autism Services Demonstration Certification Autism Services Demonstration Certification Autism Services Demonstration Certification 04/2008
Birthing Center Birthing Center Birthing Center 08/2009
Clinic or Group Practice Clinic or Group Practice Clinic or Group Practice 08/2009
Clinical Social Worker Clinical Social Worker Clinical Social Worker 08/2009
Corporate Service Corporate Service Corporate Service 08/2009
Durable Medical Equipment and Supply Durable Medical Equipment and Supply Durable Medical Equipment and Supply 08/2009
Home Health Agency Home Health Agency Home Health Agency 08/2009
Hospice Hospice Hospice 08/2009
Independent Lab Independent Lab Independent Lab 08/2009
Individual Physician Individual Physician Individual Physician 08/2009
Institutional Provider Institutional Provider Institutional Provider 08/2009
Marriage and Family Therapist Marriage and Family Therapist Marriage and Family Therapist 08/2009
Mental Health Counselor Mental Health Counselor Mental Health Counselor 08/2009
Nurse-Midwife Nurse-Midwife Nurse-Midwife 08/2009
Pastoral Counselor Pastoral Counselor Pastoral Counselor 08/2009
Pharmacy Pharmacy Pharmacy 08/2009
Physician Assistant Physician Assistant Physician Assistant 08/2009
Physiological Laboratories Physiological Laboratories Physiological Laboratories 08/2009
Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital 09/2009
Psychiatric Nurse Psychiatric Nurse Psychiatric Nurse 09/2009
Psychologist Psychologist Psychologist 08/2009
Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility 08/2009

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