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Overseas Fee and Payment Forms

Premium Payment Credit Card & EFT Authorization (TRICARE Reserve Select/TRICARE Retired Reserve)

Use this form if you would like to initiate or discontinue a TRICARE Reserve Select or TRICARE Retired Reserve premium payment using your credit/debit card or and electronic fund transfer from your bank account. Forms will be process within 10 days of receipt. Upon receipt of this form International SOS will process all outstanding charges (if any) due for your premium program balance.

Mail or fax a completed copy of page 1 of this form to International SOS.

International SOS Assistance, Inc
Attention: TRS Accounts Receivable
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1 215-354-2340

Additional instructions are found on page 2 of this form.

Premium Payment Credit Card & EFT Authorization (TRICARE Young Adult)

Use this form if you would like to initiate or discontinue a TRICARE Young Adult premium payment using your credit/debit card or and electronic fund transfer from your bank account. Forms will be process within 10 days of receipt. Upon receipt of this form International SOS will process all outstanding charges (if any) due for your TRICARE Young Adult premium program balance.

Mail or fax a completed copy of page 1 of this form to International SOS.

International SOS Assistance, Inc
Attention: TYA Accounts Receivable
PO Box 11689
Philadelphia, PA 19116
Fax: +1 215-354-2340

Additional instructions are found on page 2 of this form.

Last Updated 9/3/2013