West Region
Each of the privacy forms below can be mailed or faxed to the TRICARE West Privacy Office:
TRICARE West Region Privacy Office
This form is for use by the TRICARE beneficiary or the beneficiary’s authorized representative to request access to inspect and/or to obtain a copy of the beneficiary’s protected health information contained in the designated record set maintained by the regional contractor or the designated record set maintained for the regional contractor by one of its business associates.
This form is used by the TRICARE Beneficiary or the beneficiary's authorized representative to request the amendment of protected health information in the regional contractor designated record set or the designated records set maintained for the regional contractor by one of its business associates.
Authorization to Disclose Information
Use this Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or organization access to your PHI. Your PHI is protected by the Privacy Act, the Health Insurance Portability and Accountability Act, state laws, and the regional contractor policies and procedures. The employees of the regional contractor are trained to protect your information.
You or your authorized representative can use this form to document your request for an accounting of disclosures of your PHI.
Privacy Inquiry/Complaint Form
Use this form to submit an inquiry or complaint about TRICARE or the regional contractor HIPAA Privacy policies or practices.
You or your authorized representative can use this form to request a restriction on the use and disclosure of your PHI.
Request for Confidential Communications
You or your authorized representative can use this form to request that the regional contractor use alternative means or an alternative address for the communication of your PHI if sending communications to the address of record could endanger you.
Last Updated 9/23/2026