Follow the steps to accurately complete the claim development worksheet online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information in the provided fields. This includes the authorization number, full name, date of birth in the format AAAAMMDD, address, sex, sponsor's social security number, sponsor's name, and the relationship to the sponsor.
3. In the patient signature section, the patient or authorized person must sign and date the form. This signature certifies that the provided information is correct and authorizes the disclosure of necessary medical information to process the claims.
4. Describe the diagnosis for which the patient received treatment, supplies, or medication. If known, provide the appropriate diagnosis codes (ICD-9 or ICD-10); otherwise, write a brief description of the patient's condition.
5. Indicate whether the treatment was provided in an emergency unit by selecting 'Yes' or 'No.'
6. Fill in the patient reference number, which may be the account number, patient record number, or invoice number to assist in the payment process.
7. State if the patient has other health insurance by selecting 'Yes' or 'No.' If 'Yes,' provide the name of the insurance, the insured person's name, policy number, effective dates, and amounts paid by the other insurance.
8. Indicate any payments made by the beneficiary regarding the medical care received, specifying the total amount in the designated currency.
9. Complete the provider information section, including the provider's name and address.
10. The provider must also sign and date the form to confirm accuracy and completion.
11. Finally, review all information for accuracy, then save changes and download, print, or share the form as needed.

Complete your TRICARE overseas program claim development worksheet online today.