PROVIDERS

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

Electronic Funds Transfer (EFT) Registration Form

ERA Enrollment Form

Authorization to Disclose Information

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

Revised CMS 1500 claim 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/Notification form

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

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