Forms

TRICARE West Region beneficiaries can find a variety of forms to print to assist with claims, enrollment and billing, or customer service fulfillment.

Claims

• Appointment of Representative
• Other Health Insurance (OHI) form
• Timely filing waiver
• Authorization Appeal form

Enrollment and Billing

• Automatic Monthly TRICARE Payment Set Up Request
• Start, Change or Stop Your Allotment
• TRICARE Prime/Select/Reserve Recurring Credit Card/Electronic Funds Transfer payment (start or change request)
• TRICARE Young Adult Recurring Credit Card/Electronic Funds Transfer (start or change request)
• Enrollment Reconsideration Request

Enrollment Forms

• TRICARE Prime, Prime Remote, Prime Overseas, Prime Remote Overseas (DD 2876-2)
• TRICARE Select, Select Overseas (DD 3043-2)
• TRICARE Young Adult (DD 2947-2)

Customer Service

• Authorization to Disclose
• Potential Quality Issue Form
• West Region Grievance
• West Region Drive Time Waiver