West Region

The following forms are used to establish recurring payments, make one-time credit card payments and request refunds when needed with Health Net. 

Upon completion, send these forms to Health Net using the address or fax number found on the forms.

Prime Electronic Payment Authorization Form

Use this form to set up an automatic payments for TRICARE Prime, including an allotment.

TRR/TRS Electronic Payment Authorization Form

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

TYA Electronic Payment Authorization Form

Use this form to start, change or stop a recurring electronic payment via funds transfer or credit card with Health Net for 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).

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.