PROVIDERS

Find all the forms you need to take care of your TRICARE® business.

Authorization for Disclosure of Medical Information (DD2870)

Change of Address Form

Change of Tax Identification Number Form

CMS 1500 claim form

Electronic Funds Transfer (EFT) Registration Form  

ERA Enrollment Form

Non-Network UB-04 "Signature on File" Form

National Provider Identifier Forms

Other Health Insurance Questionnaire 

Provider Certification Forms

Reimbursement of Capital and Direct Medical Education Costs

Statement of Personal Injury / Third Party Liability (DD2527)

Taxpayer Identification Number Request (W-9)

TRICARE Service Request

Some of these forms are in Adobe PDF format. To view or print, you will need Adobe® Reader®.

Go to the North Region Prime Contractor's site to see additional forms.