Get Tricare Service Request Notification Form

Completing the Tricare Service Request Notification Form online is a straightforward process designed to streamline your request for medical services. This guide will provide you with clear instructions on how to fill out each section of the form accurately.

Follow the steps to complete the form with ease.

1. Click 'Get Form' button to access the Tricare Service Request Notification Form and open it in your selected editor.
2. Indicate the urgency of the service request by selecting the appropriate fax referral option: Routine, Urgent (care needed within 72 hours), or Inpatient. Specify the anticipated date of service along with the type of service required.
3. Complete the Admission Type section by selecting the relevant option, such as Emergency Room (ER), Direct Admit, Elective, Inpatient, or Durable Medical Equipment (DME).
4. Fill in the Beneficiary Information section carefully, ensuring all fields, including last name, first name, middle initial, address, contact phone number, gender, date of birth, and either Sponsor SSN or Benefits Number, are fully completed.
5. Provide Diagnostic Information, which includes the required diagnosis codes (ICD Code(s)), diagnosis description, and episode of care details.
6. In the Clinical Information section, describe the requested service clearly. Include any necessary attachments, specifying the therapy type and the corresponding CPT/HCPCS codes along with the number of units required.
7. Complete the Requesting Provider Information with all required fields, including last name, first name, address, NPI number, and office contact details.
8. Select the appropriate servicing provider option (physician, facility, or agency) and fill in their information including name, address, and specialty.
9. If applicable, provide details of the servicing facility, checking the relevant options such as Acute Inpatient or Outpatient, and include their contact information.
10. After completing all sections, review the form for accuracy, save your changes, and choose to download, print, or share the form as needed.

Start completing your Tricare Service Request Notification Form online today to ensure timely processing of your service requests.