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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)

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 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.