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  • Triwest Authorization To Disclose Form

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AUTHORIZATION TO DISCLOSE Instructions for completing this form: PURPOSE This Authorization to Disclose form is filled out when you (the Veteran, patient) want to grant another individual or organization.

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How will a provider know whether the Veteran is eligible? For urgent care, providers must be in-network with TriWest and call TriWest at 1-833-4VETNOW (1-833-483-8669) to confirm a Veteran's eligibility before rendering care. For ER care, VA coordinates directly with the provider and will determine eligibility.

Quick Reference Guide PC3. Key Points: A provider who determines that additional or continued care outside the scope of the original authorization is required should complete the Secondary Authorization Request (SAR) form. TriWest will then follow the appointment/scheduling process.

If the Veteran's VAMC is managing the appointing directly, then you should submit a Request for Services (RFS) directly to the authorizing VAMC. If TriWest is managing the appointing, please complete and fax a Secondary Authorization Request (SAR) form to 1-866-284-3736.

View a map of VA Community Care RegionsTriWest appoints based on NPI, however all claims, portal access and contracting is based on the tax identification number (TIN). You do not need to be associated with an authorization in our system for your claim to pay.

You need a referral from your primary care manager (PCM) for any care he/she doesn't provide. This includes urgent, routine, preventive, and specialty care services. Your PCM works with your regional contractor for the referral and authorization.

By phone at: 1-866-284-3743 By email at: providerservices@TriWest.com For new providers in PC3 Regions 1, 2 and 4, please email participation questions to triwestexpansion@triwest.com.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232