Please type your responses to complete this online form. When completed, print, then fax to the number at the bottom of the form. For additional information, you may view a sample TRICARE Patient Referral/Authorization Form Example, visit www.triwest.com/provider, or call 1-888-TRIWEST (1-888-874-9378).

Sponsor SSN:		Sponsor Name:
Patient Name:		Patient SSN:
Address:		Date of Birth:
City:		State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code:
Home Telephone:		Patient's Relationship to Sponsor:
Requesting Provider:		Contact Name:
TIN:		NPI (Optional):
Address:
City:		State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code:
Telephone:		Fax:
ICD-9 Diagnosis:	Type in the first numbers of the ICD9 code or the first letters of the description to activate the search dropdown box. Select an option from the dropdown box before proceeding. There may be a slight delay in the dropdown while typing.
Select One of the Following		Inpatient Outpatient Facility Home Office
Select One of the Following:		Routine Urgent	Urgent is defined as medically necessary services required for illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours.