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 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