Get Tricare East Referral Form

Filling out the Tricare East Referral Form online is a straightforward process that ensures appropriate care is provided to the patient. This guide will help you navigate each section of the form with ease, ensuring that all necessary information is adequately completed.

Follow the steps to fill out the Tricare East Referral Form online effectively.

1. Click ‘Get Form’ button to obtain the Tricare East Referral Form and open it for editing.
2. Begin with entering the patient's information, including their full name, Social Security number, and date of birth in the designated fields.
3. Fill in the patient's address, ensuring to include the street address, city, state, and ZIP code, as post office boxes are not allowed.
4. Complete the home telephone field and indicate the patient's relationship to the sponsor, selecting from options such as self, spouse, or child.
5. Provide details of the requesting provider, including their name, specialty, contact name, tax identification number (TIN), and National Provider Identification number (optional).
6. Enter the requesting provider's complete address and telephone number, as well as their fax number.
7. Input the required diagnosis codes using the ICD-9 format, and describe the patient's diagnosis in the designated area.
8. Select the appropriate place of service (Inpatient, Outpatient Facility, Home, or Office) and the urgency of care (Emergency, Routine, or Urgent).
9. Fill in the servicing provider's information, including their name, specialty, TIN, NPI, and complete address including city, state, and Zip code.
10. Provide contact details for the servicing provider, including telephone and fax numbers.
11. If applicable, provide the facility name where services will be rendered, along with their TIN and NPI.
12. Detail the requested service and include the necessary CPT4/HCPCS codes for the services being requested.
13. Indicate the date of service and the number of visits expected for the requested services.
14. Review all completed sections carefully to ensure accuracy and completeness.
15. Finally, save the changes made to the form, and download or print it as necessary, or share via applicable channels.

Complete your documents online today to ensure timely processing of your referral requests.