||Find all the forms you need to take care of your TRICARE® business.
Sample Form 1500 (02/12)
Authorization for Disclosure of Medical Information (DD2870)
Change of Address Form
Change of Tax Identification Number Form
Electronic Data Interchange (EDI) forms
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
Provider Fax Cover Sheet
Provider Fax Separator Sheet (Please note: For providers who want to fax information for multiple patients, please use a fax separator sheet between each patient's correspondence. Please do not use photocopies of the fax separator sheet.)
Provider Refund Form- Single Claim
Provider Refund Form- Multiple Claims
Reimbursement of Capital and Direct Medical Education Costs
Statement of Personal Injury / Third Party Liability (DD2527)
TRICARE Service Request forms
Taxpayer Identification Number Request (W-9) (Please Note: Fax completed W-9 to 803-735-8742. For B-Notice or 1099 related questions, please call 1-800-991-2701 and select option 1 or 803-763-6368 for assistance.)
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.