West Region

You can use the following forms to establish recurring payments, make one-time credit card payments, and request refunds when needed.  

Start, Change, or Stop Allotments for TRICARE Fees/Premiums

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

TRR/TRS Electronic Payment Authorization Form

Use this form to start, change, or stop a recurring payment via electronic funds transfer or credit card  for:

• TRICARE Prime enrollment fees
• TRICARE Reserve Select or TRICARE Retired Reserve monthly premiums

You'll also use this form to make your initial payment when you first enroll (with check or credit card).

TYA Electronic Payment Authorization Form

Use this form to start, change or stop a recurring payment via electronic funds transfer or credit card for:

• TRICARE Young Adult monthly premiums

You'll also use this form to make your initial payment when you first enroll (with check or credit card).

One-Time Credit Card Payment Form

Use this form to submit a one-time credit card payment for:

• TRICARE Prime enrollment fees
• TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult monthly premium payments

No information will be saved for future payments when using this form.