Get Tricare Reconsideration Form

Filling out the Tricare reconsideration form online can streamline the process of requesting reconsideration for involuntary disenrollment or late initial enrollment. This guide provides clear steps to help you complete the form accurately and efficiently.

Follow the steps to complete the Tricare reconsideration form online

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the TYA beneficiary's name in the designated field. This should be the person who is requesting the reconsideration.
3. Fill in the date of request in the MM/DD/YYYY format. Be sure to use the correct date as this may be relevant for your case.
4. Provide the sponsor's Social Security Number (SSN) in the format XXX-XX-XXXX, followed by the TYA beneficiary's SSN, also in the same format.
5. Enter a contact phone number, ensuring it is accurate for any follow-up communications.
6. Complete the address section for the TYA beneficiary. Ensure it is complete and includes street, city, state, and ZIP code.
7. Mark the appropriate checkbox to indicate whether your request is for involuntary disenrollment or late initial enrollment.
8. In the provided text box, clearly explain the reason for your reconsideration request. Include any relevant details, such as the reason for disenrollment and any extraordinary circumstances.
9. If necessary, attach additional pages with further details as needed.
10. Provide your signature to confirm the validity of the request.
11. Proceed to the second page of the form. Fill out the electronic funds transfer (EFT) or auto charge information, providing the required bank or credit card details.
12. Once completed, you may save the changes, download, print, or share the filled-out form as necessary.

Complete your paperwork online to ensure a smooth reconsideration process.