Get Tricare Service Request/notification Form

Filling out the TRICARE Service Request/Notification Form online is a crucial step for ensuring timely access to medical care. This guide provides comprehensive instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the TRICARE Service Request/Notification Form online

1. Click ‘Get Form’ button to obtain the TRICARE Service Request/Notification Form and open it in your preferred editor.
2. Indicate the type of admission by selecting either 'Emergency Admit' or 'Elective Admit.' For emergency admissions, ensure to enter the sponsor’s Social Security number if a face sheet is attached.
3. In the 'Physical Health Facility Type' section, select the appropriate type of facility, such as Acute Care Hospital or Skilled Nursing Facility, depending on the patient's needs.
4. Provide 'Patient Information' by filling in the patient's date of birth, last name, first name, address, and phone numbers. Ensure all details are accurate.
5. In the 'Other Health Insurance' section, indicate 'Yes' or 'No' if the patient has additional coverage. If yes, provide the policy number and carrier details.
6. Provide 'Requesting Provider Information,' including provider name, phone number, and tax identification number. Indicate whether the requesting provider is performing the service.
7. Fill out the 'Servicing Provider Information' with the required details about the servicing provider and the hospital or healthcare facility.
8. Under 'Requested Service,' list the diagnosis codes and descriptions for the services needed. Include CPT codes, units, and frequency, making sure to attach additional sheets if necessary.
9. In the 'Additional Comments' section, submit any clinical information that may assist in processing the request.
10. Once you have filled out all sections, review the form for accuracy, then save your changes. You can then download, print, or share the completed form as needed.

Complete and submit your TRICARE Service Request/Notification Form online today to facilitate your healthcare needs.