TRICARE Other Health Insurance (OHI) Form
TO BE COMPLETED BY THE OHI POLICY HOLDER
Section I: Personal Information
Beneficiary's Social Security #: * Beneficiary's Date of Birth *
Beneficiary's Last Name: *
First Name: * MI:
Sponsor's Social Security #: * Sponsor's Date of Birth: *
Sponsor's Last Name: *
First Name: * MI:
Sponsor's Mailing Address: *
City: *
State: Zip Code: *
Sponsor's Home Phone: * Sponsor's Work Phone:
Sponsor's e-mail address: *
Section II: OHI Information
Does anyone in your family have OHI? *
If yes, what is the coverage type (see cover page for detail)?




Does this OHI Include pharmacy benefits?
Does this OHI include any mental health benefits?
Is this OHI through:
OHI Policy Holder's Name:
Relationship to Sponsor:
Names of anyone else covered under this policy:
1: 2:
3: 4:
If OHI is through an employer, please provide the following information:
Name of Insurance company:
Insurance Company Address:
City:
State: Zip Code:
Employer Name:
Employer Address:
City:
State: Zip Code:
Policy Number: Group Number:
Effective Date: Termination Date:
Section III: Medicare Information
Medicare Health Insurance Number:
Effective Date - Hospital (Part A): Effective Date - Medical (Part B):