To submit this form, complete all necessary fields and ensure your information is accurate. You can submit your request online through the TRICARE portal, or send completed forms via fax to the appropriate department. Make sure to keep a copy of your submission for your records.

Important dates for TRICARE processes may vary each year, so it's essential to stay updated. For 2024 and 2025, be aware of changes in costs and authorization processes typically announced at the beginning of the year. Always check relevant TRICARE resources for timely updates.

The purpose of this form is to standardize the authorization and referral process for TRICARE services. It ensures that beneficiaries understand the requirements necessary to receive care outside military facilities. By providing a clear guide, it helps avoid delays and ensures smooth access to healthcare.

• 1. Beneficiary Name: The full name of the individual requesting services.
• 2. TRICARE Plan: The specific plan the beneficiary is enrolled in.
• 3. Requested Service: Details about the medical service or specialty care needed.
• 4. Provider Information: The name and contact information of the service provider.
• 5. Authorization Number: Tracking number for the authorization request.

Failing to submit this form may lead to delays in receiving necessary medical care. Without proper authorization, beneficiaries may not be able to access services, resulting in potential out-of-pocket costs. It also complicates the administration of TRICARE benefits.

• Delayed Care: Without approval, care may be postponed.
• Out-of-Pocket Expenses: Unapproved services could incur additional costs.
• Complicated Processing: Failure to submit can lead to confusion and delays in service.

• 1. Specialty Care Requests: For services needing referral to a specialist.
• 2. Out-of-Network Services: When accessing care from non-TRICARE providers.
• 3. Periodic Checks: Regularly confirm ongoing authorizations as needed.