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West Region Forms

Go to the West Region Forms Page

Enrollment Applications

Select the form for the plan you want to enroll in/purchase:

Mail or fax the completed application to UnitedHealthcare at:

TRICARE West Region
Enrollment Department
P.O. Box 105492
Atlanta, GA 30348-5492

Fax: 1-877-890-7297

Payment/Fee Authorization Forms

Mail or fax any of the following payment/fee authorization forms to UnitedHealthcare at:

TRICARE West Region
Enrollment Department
P.O. Box 105492
Atlanta, GA 30348-5492

Fax: 1-877-890-7297

Electronic Payment Authorization Form

Use this form to start, change or stop a recurring electronic payment via funds transfer or credit card with UnitedHealthcare for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premiums. You'll also use this form to make your initial payment with you first enroll (with check or credit card).

If you are currently covered by one of these health plan options under TriWest, you need to submit this form to UnitedHealthcare by March 11, 2013 to re-establish your recurring electonic payments through UnitedHealthcare.

One-Time Credit Card Payment Form

This form is used to submit a one-time credit card payment for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premium payments. No information will be saved for future payments when using this form.

Refund Request Form for Beneficiary Fees/Premiums

Use this form to request a refund for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premiums. Refunds are only granted due to life-changing events (i.e. active duty orders, death, etc.) and supporting documentation is required. Refund requests may take four to six weeks for processing.

Privacy Forms

Each of the privacy forms below can be mailed or faxed to the TRICARE West Region Privacy Office:

UnitedHealthcare Military & Veterans
TRICARE West Region Privacy Office
P.O. Box 105661
Atlanta, GA  30348-5661

Fax: 1-877-894-1493

Access Request

This form is for use by the TRICARE beneficiary or the beneficiary’s authorized representative to request access to inspect and/or to obtain a copy of the beneficiary’s protected health information (PHI) contained in the designated record set maintained by UnitedHealthcare or the designated record set maintained for UnitedHealthcare by one of its business associates. 

Amendment Request

This form is used by the TRICARE Beneficiary or the beneficiary's authorized representative to request the amendment of PHI in the UnitedHealthcare designated record set or the designated records set maintained for UnitedHealthcare by one of its business associates.

Authorization to Disclose Information

This Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or organization access to your PHI. Your PHI is protected by the Privacy Act, the Health Insurance Portability and Accountability Act (HIPAA), state laws, and UnitedHealthcare policies and procedures. The employees of UnitedHealthcare Military & Veterans are trained to protect your information. 

Disclosure Accounting Request

This form is for use by the TRICARE beneficiary or the beneficiary’s authorized representative to document the beneficiary’s request for an accounting of disclosures of his/her PHI.   

Privacy Inquiry/Complaint Form

This form is for the use by a TRICARE beneficiary to submit an inquiry or complaint about TRICARE or UnitedHealthcare HIPAA Privacy policies or practices.  

Restriction Request

This form is for use by beneficiaries or their authorized representative to request that a restriction be placed on the use and disclosure of the beneficiary’s PHI.

Request for Confidential Communications

This form is for use by a TRICARE beneficiary or the beneficiary’s authorized representative to request that UnitedHealthcare use alternative means or an alternative address for the, communication of the beneficiary’s PHI in the event that sending communications to the address of record could endanger the beneficiary.

Other Forms

Grievance Form

Submit this form if you have a complaint or grievance to file reagarding a provider or services by UnitedHealthcare. Submit the form to:

UnitedHealthcare Military & Veterans
TRICARE West Region
Attn: Grievances
P.O. Box 105493
Atlanta, GA 30348-5493

Fax: 1-877-584-6628

Other Health Insurance Questionnaire

Complete this form to notify UnitedHealthcare if you have other health insurance. When you do, TRICARE is the second payer. Send the completed for to:

TRICARE West Region
Claims Department
P.O. Box 7064
Camden, SC  29020-7064

Last Updated 9/3/2013