PROVIDERS

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Provider Forms


forms 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)

Electronic Data Interchange (EDI) forms

Electronic Funds Transfer (EFT) Registration Form

ERA Enrollment Form

Non-Network Provider Information Update Request Form

Non-Network Practitioner Affiliation/Disaffiliation Request Form

Non-Network Signature Authorization 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.)

 

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

 

 


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