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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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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 12/2009
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) 10/2007
Other Health Insurance Form (OHI) (Spanish) Other Health Insurance Form (OHI) (Spanish) Other Health Insurance Form (OHI) (Spanish) 10/2007
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 02/2010
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 01/2010
Inpatient Emergency Admission - Mental Health Inpatient Emergency Admission - Mental Health Inpatient Emergency Admission - Mental Health 01/2010
PCM Communication Form PCM Communication Form PCM Communication Form 03/2010
Preauthorization for Electroconvulsive Therapy (ECT) Preauthorization for Electroconvulsive Therapy (ECT) Preauthorization for Electroconvulsive Therapy (ECT) 01/2010
Preauthorization for Inpatient Substance Abuse Rehabilitation Preauthorization for Inpatient Substance Abuse Rehabilitation Preauthorization for Inpatient Substance Abuse Rehabilitation 01/2010
Preauthorization for Outpatient Treatment Request Preauthorization for Outpatient Treatment Request Preauthorization for Outpatient Treatment Request 01/2010
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 01/2010
Preauthorization for Psychological/Neuropsychological Testing Preauthorization for Psychological/Neuropsychological Testing Preauthorization for Psychological/Neuropsychological Testing 03/2010
Residential Treatment Center (RTC) Application Residential Treatment Center (RTC) Application Residential Treatment Center (RTC) Application 03/2010

Certification
Form Name File Type Fill & Print Revision
Allied Health Allied Health Allied Health 04/2010
Ambulance Ambulance Ambulance 04/2010
Ambulatory Surgical Centers Ambulatory Surgical Centers Ambulatory Surgical Centers 04/2010
Autism Services Demonstration Certification Autism Services Demonstration Certification Autism Services Demonstration Certification 06/2010
Birthing Center Birthing Center Birthing Center 04/2010
Clinic or Group Practice Clinic or Group Practice Clinic or Group Practice 04/2010
Clinical Social Worker Clinical Social Worker Clinical Social Worker 04/2010
Corporate Service Corporate Service Corporate Service 04/2010
Durable Medical Equipment and Supply Durable Medical Equipment and Supply Durable Medical Equipment and Supply 04/2010
Home Health Agency Home Health Agency Home Health Agency 04/2010
Hospice Hospice Hospice 04/2010
Independent Lab Independent Lab Independent Lab 04/2010
Individual Physician Individual Physician Individual Physician 04/2010
Institutional Provider Institutional Provider Institutional Provider 04/2010
Marriage and Family Therapist Marriage and Family Therapist Marriage and Family Therapist 08/2009
Mental Health Counselor Mental Health Counselor Mental Health Counselor 04/2010
Nurse-Midwife Nurse-Midwife Nurse-Midwife 04/2010
Pastoral Counselor Pastoral Counselor Pastoral Counselor 04/2010
Pharmacy Pharmacy Pharmacy 04/2010
Physician Assistant Physician Assistant Physician Assistant 04/2010
Physiological Laboratories Physiological Laboratories Physiological Laboratories 04/2010
Psychiatric Hospital Psychiatric Hospital Psychiatric Hospital 04/2010
Psychiatric Nurse Psychiatric Nurse Psychiatric Nurse 09/2009
Psychologist Psychologist Psychologist 04/2010
Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility 04/2010

Clinical Programs
Form Name File Type Fill & Print Revision
Cancer Clinical Trials Patient Authorization Form Cancer Clinical Trials Patient Authorization Form Cancer Clinical Trials Patient Authorization Form 01/2010
Case Management Referral Form Case Management Referral Form Case Management Referral Form 06/2010
ECHO and Autism Patient Referral Form ECHO and Autism Patient Referral Form ECHO and Autism Patient Referral Form 06/2010
Hospice Authorization Form Hospice Authorization Form Hospice Authorization Form 03/2010
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 03/2010
TBI Program Referral Form TBI Program Referral Form TBI Program Referral Form 04/2010

Clinical Information
 
Injectable Medications      
Injectable Medications Injectable Medications Injectable Medications 06/2010
Synagis Synagis Synagis 06/2010
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 06/2010
Insulin Pump Insulin Pump Insulin Pump 06/2010
Wheeled Mobility Wheeled Mobility Wheeled Mobility 06/2010
 
Therapies      
Nutritional Therapy Nutritional Therapy Nutritional Therapy 04/2010

* Registered users no longer need to fax this form. Submit your refs/auths online for a quicker response. Register today!