||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
NEW! Non-Network Provider Information Update Request Form
NEW! 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.)
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.