Premium Payment Credit Card & EFT Authorization

Use this form if you would like to initiate or discontinue a TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult premium payment using your credit/debit card and/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.
  • Address and fax number is found on the form.
  • Additional instructions are found on page 2 of this form.

Last Updated 11/29/2019