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Fee Payments
Form Name PDF Fill &
Print		 Online PDF Revision
Allotment Authorization Letter – TRICARE Prime
( FM533BEW07084 ) 		07/2008
Collection Resolution Request Form
( FR901004BEAL0107 ) 		01/2007
Electronic Payment Authorization Form - TRICARE Prime
( FR800009BEAL0408 ) 		04/2008
Electronic Payment Authorization Form - TRICARE Reserve Select (TRS)
( FR800010BEAL1208 ) 		12/2008
Enrollment Fee Refund Request – TRICARE Prime and TRS
( FR900005BEAL0107 ) 		01/2008

Health Insurance Portability and Accountability Act (HIPAA)
Form Name PDF Fill &
Print		 Online PDF Revision
Authorization to Disclose Form
( FR910013BEAL0908 ) 		09/2008
HIPAA Access Request Form
( FR911005BEAL0904 ) 		09/2004
HIPAA Amendment Request Form
( FR911006BEAL0904 ) 		04/2004
HIPAA Complaint Form
( FR911004BEAL0904 ) 		09/2004
HIPAA Confidential Communication Form
( FR911002BEAL0704 ) 		07/2004
HIPAA Disclosure Accounting Request
( FR911007BEAL0904 ) 		09/2004
HIPAA Restriction Request
( FR911003BEAL0704 ) 		07/2004

Claims
Form Name PDF Fill &
Print		 Online PDF Revision
Appointment of Representative for Appeal
( FR920001BEAL1008 ) 		10/2008
Beneficiary Claim Form
( DoD Form: 2642 ) 		04/2007
Other Health Insurance Form (OHI)
( FR901003BEAL0107 ) 		01/2007
Third Party Liability
( DoD Form: 2527 ) 		01/2008
Waiver of Non-Covered Services
( FR440017PRAL0107 ) 		01/2007

Enrollment Forms
Form Name PDF Fill &
Print		 Online PDF Revision
Continued Health Care Benefits Program Enrollment Form (CHCBP)
( DoD Form: 2837 ) 		09/2006
TRICARE Prime Disenrollment Form
( DoD Form: 2877 ) 		04/2007
TRICARE Prime Enrollment Application & PCM Change Form
( DoD Form: 2876 ) 		04/2007
TRICARE Reserve Select (TRS) Information Update Form
( N/A ) 		04/2005

Spanish Forms
Form Name PDF Fill &
Print		 Online PDF Revision
Formulario de TRICARE sobre la cobertura de Otro Seguro Médico (OHI)
( FM591BEW01084SP )		 01/2008
Letra De la Autorización De la Asignación Del Honorario De la Inscripción
( FM561BEW02084SP )		 02/2008
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