East Region

Automatic Credit/Debit Card Charge

Use this form to establish automatic payments on your debit or credit card for TRICARE Prime enrollment fees or monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult. Submit this completed form to:

The address and fax number for submission are on the form.

Enrollment Fee Allotment Authorization

TRICARE Prime beneficiaries should use this form to start, change or stop automatic deduction of enrollment fees from their military retirement pay.

This form is completed online.

Monthly Automatic Electronic Funds Transfer from Checking or Savings Account

Use this form to set up automatic payments for TRICARE Prime enrolllment fees or monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult using an electronic funds transfer.

This form is completed online.