To submit this form, you can do so online via TRICARE's official website, simply accessing the 'Submit a Claim' section. Alternatively, fax the completed form to 1-844-730-1367. For mail, send it to TRICARE West Correspondence, PO Box 202100, Florence, SC 29502-2100. Ensure that all required fields are completed accurately before submission for fastest processing.

Important dates for this form include submission deadlines aligned with policy changes in 2024-2025. Ensure timely submissions for any expected changes in eligibility requirements or benefits. Check regularly for updates to maximize your coverage.

The purpose of this form is to facilitate access to breast pump equipment and supplies for TRICARE beneficiaries. It provides a structured process to ensure beneficiaries can receive necessary resources during and after pregnancy. Completing this form accurately ensures that claims are processed efficiently for timely support.

• 1. Order Date: The date when the order is placed.
• 2. Provider Name: The name of the healthcare provider prescribing the breast pump.
• 3. Patient Name: The name of the patient requiring the breast pump.
• 4. Patient Address: The address where the patient can be reached.
• 5. Diagnosis Code: The applicable medical diagnosis code.
• 6. Benefit Qualification: The qualifying event for which the benefits are claimed.
• 7. NPI: National Provider Identifier of the prescriber.
• 8. Fax: Fax number for submission.
• 9. Sponsor SSN/Patient DBN: Social Security Number or Defense Benefits Number.
• 10. Description: Description of the requested breast pump.
• 11. Signature: Required signature from the healthcare provider.

Failure to submit this form can lead to delays in receiving necessary breast pump supplies. Without proper submission, beneficiaries may miss out on timely coverage for essential items. Correct and prompt submission is critical to ensure claims are honored.

• Missed Prescription Coverage: Delaying the submission could mean missing out on benefits associated with the required breast pump.
• Delayed Access to Supplies: Failure to submit can extend the time before beneficiaries receive the needed supplies.
• Increased Out-of-Pocket Expenses: Not submitting the form promptly might lead to additional costs that would otherwise be covered.

• 1. Pregnancy Support: Use this form during the third trimester to request necessary supplies.
• 2. Postpartum Needs: Post-birth requests for breast pumps and necessary accessories also require this form.
• 3. Adoption Cases: Legally adopting parents intending to breastfeed will need to submit this form.