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F43039 TRICARE PATIENT REFERRAL/AUTHORIZATION FORM Use this form for West Region Medical/Surgical Requests Only Attach the following: Clinical notes, history & physical, appropriate lab results.

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Who Needs a Referral? Note: Active duty service members enrolled in TRICARE Prime Remote do not require a referral for urgent care due to their remote location. Beneficiaries enrolled in TRICARE Prime plans who are not active duty service members require a referral for most, but not all, specialty care.

A referral is when your primary care manager (PCM) or provider sends you to another provider for care that he/she doesn't provide. If you're an active duty service member enrolled in TRICARE Prime, your PCM works with your regional contractor for the referral.

Those eligible for TRICARE include: Active duty service members and families. National Guard/Reserve members and families. Retired service members and families. Retired Reserve members and families. Beneficiaries eligible for TRICARE and Medicare. Survivors. Children. Former spouses.

Your PCM will send a referral request to your regional contractor, who'll process the referral. It can take approximately three business days for your regional contractor to process your referral. It may take less time if your PCM determines your referral to be “clinically urgent” and marks it as such.

If You Are Enrolled in a TRICARE Prime Plan You must get a referral from your primary care manager (PCM) before seeking pregnancy care. You may not self-refer to an obstetrician or gynecologist even for your pregnancy. Your PCM will refer you to a military hospital or clinic, if available.

TRICARE referrals should be submitted through .humanamilitary.com (log on to Self-Service for Providers). If you do not have internet connection in your office, you may complete and submit this form by fax to 1-877-548-1547.

TRICARE Prime Prime enrollees may receive clinical preventive services from any network provider without a referral or authorization. Urgent care visits do not require referrals.

Create a new referral or authorization The quickest, easiest way to request a new referral or authorization or update an existing referral or authorization is through provider self-service. *Providers should submit referrals and authorizations (including behavioral health) through self-service.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232