Get Tricare Patient Referral Authorization Form 2019-2025

Filling out the Tricare Patient Referral Authorization Form online is a straightforward process that ensures your medical referrals are processed efficiently. This guide will provide step-by-step instructions on how to accurately complete the form and submit it for approval.

Follow the steps to successfully complete the form online

1. Click ‘Get Form’ button to access the Tricare Patient Referral Authorization Form and open it in your preferred format.
2. Begin by entering the patient’s name in the designated field. Ensure you provide the full name as it appears on official documents.
3. In the next field, input the patient’s phone number, which will be necessary for any follow-up communication.
4. Provide the TRICARE ID number in the appropriate section. This is essential for identification and processing.
5. Enter the patient's date of birth in the mm-dd-yyyy format to maintain accuracy.
6. Fill in the sponsor's address, making sure to include complete details to avoid any issues with correspondence.
7. Indicate whether the patient has other health insurance by checking the appropriate box and provide details about the carrier and policy number if applicable.
8. Select the provider or setting from the options available: Physician’s office, Allied health professional’s office, Outpatient facility, or Inpatient facility.
9. If known, indicate the date of service in the specified format.
10. Select whether the referral is for evaluation only or to evaluate and treat, based on the patient's needs.
11. Provide the point of contact’s name and their phone number, ensuring that this person can respond to any inquiries.
12. Fill in the ordering provider’s name, phone number, and fax number for easy communication.
13. Choose the type of service required, such as an office visit or specific therapies, and list any specialties if necessary.
14. For inpatient referrals, provide a diagnosis code and any relevant procedure or HCPC code.
15. Complete the facility information, including its name, tax ID/NPI, and address, to direct the referral appropriately.
16. Describe the presenting symptoms or reasons for the referral clearly.
17. Include any pertinent medical history, findings, or special situations related to the patient’s care.
18. Once all fields are completed, review the form for accuracy. Then, save changes, download, print, or share the form as needed for submission.

Start filling out your Tricare Patient Referral Authorization Form online today for streamlined referral management.