Get Prime Travel Benefit Request Form

Filling out the Prime Travel Benefit Request Form online is a straightforward process that ensures you receive the necessary travel benefits. This guide provides detailed and step-by-step instructions to help you navigate each section of the form effectively.

Follow the steps to successfully complete your request form.

1. Click 'Get Form' button to access the form and open it for editing.
2. Begin by entering the patient's information, including their name, date of birth, Social Security Number (SSN), and email address. Ensure all details are accurate and clearly legible.
3. Next, provide the Primary Care Manager (PCM) information by entering the PCM’s name, address, and phone number. This is essential for verifying your medical management.
4. In the Appointment Information section, fill out the authorization number, travel departure date, and travel return date. Be sure to indicate if the appointment involved inpatient care by selecting 'Yes' or 'No' and provide the admission and discharge dates as applicable.
5. Complete the Specialty Care Provider (SCP) information by entering the SCP's name, address, and phone number, as well as the type of specialty care being sought.
6. For the sponsor's information, input the sponsor's name, SSN, status (either active duty or retired), and branch of service. Mention the mode of travel selected for the trip.
7. If applicable, provide details for the Non-Medical Attendant (NMA) including their name, SSN, relationship to the patient, and additional employment information. This information is crucial for verifying attendance eligibility.
8. Once all fields are completed, review the information for accuracy and completeness. After confirming that everything is correct, you can save any changes made to the form.
9. Finally, download, print, or share the completed form as needed to submit your request.

Complete your Prime Travel Benefit Request Form online today for a seamless experience.