General
|
| Form Name |
File Type |
Fill & Print
|
Revision |
| An Important Message from TRICARE |
|
|
02/2008 |
| Electronic Remittance Advice |
|
|
11/2008 |
| Other Health Insurance Form (OHI) |
|
|
01/2007 |
| Other Health Insurance Form (OHI) (Spanish) |
|
|
01/2005 |
| Third Party Liability Form |
|
|
10/2004 |
| TriWest Provider EDI Agreement Form |
|
|
11/2008 |
| Waiver of Non-Covered Services |
|
|
01/2007 |
| Waiver of Non-Covered Services - Sample |
|
|
01/2008 |
Medical/Surgical Referral/Authorization
|
| Form Name |
File Type |
Fill & Print
|
Revision |
| TRICARE Patient Referral/Authorization Form |
|
|
10/2008 |
| TRICARE Patient Referral/Authorization Form - Sample |
|
|
10/2008 |
Behavioral Health
|
| Form Name |
File Type |
Fill & Print
|
Revision |
| Inpatient Emergency Admission - Detox |
|
|
01/2008 |
| Inpatient Emergency Admission - Mental Health |
|
|
01/2008 |
| PCM Communication Form |
|
|
03/2007 |
| Preauthorization for Electroconvulsive Therapy (ECT) |
|
|
01/2007 |
| Preauthorization for Inpatient Substance Abuse Rehabilitation |
|
|
01/2008 |
| Preauthorization for Outpatient Treatment Request |
|
|
01/2008 |
| Preauthorization for Outpatient Treatment Request - Sample |
|
|
09/2008 |
| Preauthorization for Partial Hospitalization |
|
|
01/2008 |
| Preauthorization for Psychological/Neuropsychological Testing |
|
|
12/2008 |
| Residential Treatment Center (RTC) Application |
|
|
01/2008 |
Certification
|
| Form Name |
File Type |
Fill & Print
|
Revision |
| Allied Provider Certification |
|
|
12/2006 |
| Ambulance Certification |
|
|
12/2006 |
| Autism Provider Certification Application |
|
|
04/2008 |
| Certified Nurse Midwife Certification |
|
|
12/2006 |
| Certified Psych Nurse Specialist Certification |
|
|
12/2006 |
| Clinic or Group Practice Certification |
|
|
12/2006 |
| Clinical Psychologist Certification |
|
|
12/2006 |
| Clinical Social Worker Certification |
|
|
12/2006 |
| DME Certification |
|
|
12/2006 |
| Home Health Certification |
|
|
12/2006 |
| Independent Lab Certification |
|
|
01/2007 |
| Individual Physician Certification |
|
|
12/2006 |
| Institutional Certification |
|
|
12/2006 |
| Marriage and Family Therapist Certification |
|
|
12/2006 |
| Mental Health Counselor Certification |
|
|
12/2006 |
| Pastoral Counselor Certification |
|
|
12/2006 |
| Pharmacy Non-Retail Certification |
|
|
12/2006 |
| Physician Assistant Certification |
|
|
12/2006 |
| Physiological Lab Certification |
|
|
12/2006 |
| Skilled Nursing Facility Certification |
|
|
12/2006 |
Clinical Programs
|
| Form Name |
File Type |
Fill & Print
|
Revision |
| Applied Behavioral Analysis |
|
|
10/2005 |
| Cancer Clinical Trials Patient Authorization Form |
|
|
04/2008 |
| Case Management Referral Form |
|
|
01/2007 |
| Condition Management Notification Form |
|
|
05/2007 |
| Qualifying Condition Determination for ECHO-Referral |
|
|
01/2005 |
| Quality Management (QM) Potential Quality Issue (PQI) Referral |
|
|
05/2004 |
| Referral for TRICARE 1:1:1 Program |
|
|
06/2008 |
Clinical Information
|
| Dental |
File Type |
Fill & Print
|
Revision |
| Hospital Charges for Non-Adjunctive Dental Care |
|
|
01/2008 |
| Iatrogenic Dental Trauma Treatment |
|
|
01/2008 |
| Oral Surgery/Orthodontia |
|
|
01/2008 |
| Temporomandibular Joint Dysfunction Treatment |
|
|
01/2008 |
| |
| Injectable Medications |
|
|
|
| Injectable Medications |
|
|
01/2008 |
| Synagis |
|
|
01/2008 |
| Xolair |
|
|
01/2008 |
| |
| Medical Equipment/Supplies |
|
|
|
| C-leg Microprocessor Lower Limb Prosthesis |
|
|
01/2008 |
| Insulin Pump |
|
|
01/2008 |
| Wheeled Mobility |
|
|
01/2008 |
| |
| Therapies |
|
|
|
| Nutritional Therapy |
|
|
01/2008 |
