Overseas

Premium Payment Credit Card & EFT Authorization

Use this form if you'd like to start or stop a TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult premium payment using your credit or debit card or electronic fund transfer from your bank account.

Forms will 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.
• You can find the address and fax number on the form.
• Additional instructions are found on page 2 of this form.