Get Electronic Payment Authorization Form - Tricare - Tricare

This guide provides clear instructions on how to complete the Electronic Payment Authorization Form for Tricare users. By following these steps, you can ensure your payment preferences are set up correctly and efficiently.

Follow the steps to complete the form successfully.

1. Click 'Get Form' button to access the form and open it in your preferred editor.
2. Select the appropriate coverage option that applies to you by checking the corresponding box: Prime, TRS, TRR, or TYA. Then, enter the sponsor's name, social security number (SSN) or databases number (DBN) as required. If applicable, fill in the TYA beneficiary's details too.
3. Choose the action you would like to take by selecting from: 'Start First Time Request', 'Change Request to Existing', or 'Stop Request to Existing'. Complete the relevant steps depending on your selection.
4. For starting or changing your payment option, select either 'Electronic Funds Transfer (EFT)' or 'Recurring Credit Card (RCC)'. Provide all necessary details such as the name of the financial institution, account holder, routing number, and account number for EFT, or card details for RCC.
5. Next, if you are starting your payment request, you need to prepay two months' premiums or enrollment fees. Choose your payment method: either by check or credit card. Fill out the relevant sections based on your choice.
6. Finally, authorize your request by providing your signature. Include the date of signing and ensure to return the form by mail or fax to the specified addresses.

Complete your Electronic Payment Authorization Form online to manage your TRICARE payments effectively.