Allotment Authorization Letter     En Español
Used by beneficiaries if they choose the allotment option.

1. Open the Allotment form by clicking on the above.
2. Print two copies of the Allotment form.
3. Read form instructions carefully.
4. Complete all blocks on the form and sign.
5. Mail the completed form to the address on form, retain a copy for your records.

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Appointment of Representative   
Used by beneficiaries to appoint a representative.

1. Open the Appointment form by clicking on the above.
2. Print two copies of the Appointment form.
3. Read form instructions carefully.
4. Complete all blocks on the form and sign.
5. Submit the form to the address listed, retain a copy for your records.

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Claim Form  (DD2642) 
Used by beneficiaries to file a TRICARE healthcare claim.

1. Open the claim form by clicking on the link above.
2. Print two copies of each claim form.
3. Read claim form instructions.
4. Complete all 12 blocks on the form and sign.
5. Mail one completed copy to the following address:
   
   PGBA
   P.O. Box 7031
   Camden, SC 29020-7031
   

6. Retain a copy for your records

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Continued Health Care Benefits Program Enrollment Form (CHCBP) 
Used by beneficiaries to enroll in the Continued Health Care Benefit Program.

1. Download the enrollment form by clicking on the above.
2. Print one copy of the CHCBP Enrollment form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail the completed form and applicable enrollment fee to the address shown on the form, retain a copy for your records.

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Electronic Funds Transfer Authorization Form (EFT) - *Prime   
Used by beneficiaries to authorize HMHS the ability to transfer funds electronically in order to make monthly payments.*Not to be used by TRICARE Reserve Select beneficiaries.

1. Download the EFT form by clicking on the link to the left.
2. Print one copy of the EFT form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail one completed copy to the address on the form, retain a copy your records.

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Electronic Funds Transfer Authorization Form (EFT) - *TRICARE Reserve Select    
Used by beneficiaries to authorize HMHS the ability to transfer funds electronically in order to make monthly payments.*Not to be used by TRICARE Prime beneficiaries.

1. Download the EFT form by clicking on the link to the left.
2. Print one copy of the EFT form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail one completed copy to the address on the form, retain a copy your records.

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Lockout Waiver Request Form  
Used by beneficiaries - disenrolled from TRICARE Prime voluntarily or for non-payment of enrollment fees - to request an override of the 12 month TRICARE Prime enrollment lock-out.

1. Open the Waiver Form.
2. Print two copies.
3. Complete all blocks on the form and sign.
4. Mail or fax the completed form to the address on form, retain a copy for your records.

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Other Health Insurance Coverage Questionnaire (OHI)    En Español
Used by beneficiaries if they have Other Health Insurance.

1. Open the OHI form by clicking on the link above.
2. Print two copies of the OHI form.
3. Read form instructions carefully.
4. Complete the form and sign.
5. Complete all 12 blocks on the form and sign.
6. Mail the completed form to the address on form, retain a copy for your records.

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Public Facility Use Certification Form 
Used by beneficiaries to obtain confirmation that speech therapy for beneficiaries aged 3-21, cannot be received from the local school system.

1. Open the form by clicking on the link above.
2. Print two copies of the form.
3. Read form instructions carefully.
4. Fax the completed form to 1-877-548-1547, retain a copy for your records.

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Third Party Liability Claim Form   (DD2527) 
Used by beneficiaries when filing a TRICARE healthcare claim that may have been caused by another individual or entity.

1. Open the claim form by clicking on the link above.
2. Print two copies of the claim form.
3. Read claim form instructions carefully.
4. Complete all 13 blocks on the form and sign.
5. Mail or fax completed copy to the address on form, retain a copy for your records.

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TRICARE Reserve Select (TRS) Auto Charge Request Form   
Used by beneficiaries who would like to have their TRS premiums automatically charged to their debit or credit card each month.

1. Open the claim form by clicking on the link above.
2. Print two copies of the request form.
3. Read claim form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail or fax completed copy to the address on form, retain a copy for your records.

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TRICARE Reserve Select (TRS) Reinstatement Request Form   
Used by beneficiaries who have been denied enrollment in the TRICARE Reserve Select (TRS) program to appeal the decision.

1. Open the claim form by clicking on the link above.
2. Print two copies of the request form.
3. Read claim form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail or fax completed copy to the address on form, retain a copy for your records.

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Authorization for Release of Information Form - General  
Used by beneficiaries to authorize HMHS to use or disclosure personal health information as described.      

1. Download the ROI form by clicking on the link to the left.
2. Print one copy of the ROI form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail one completed copy to the address on the form, retain a copy your records.

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Authorization for Release of Information Form - Sensitive Diagnosis   
For use by beneficiaries to authorize HMHS to use or disclosure SENSITIVE DIAGNOSIS personal health information as described. A sensitive diagnosis is:

1. Download the ROI form by clicking on the link to the left.
2. Print one copy of the ROI form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail one completed copy to the address on the form, retain a copy your records.

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Used by beneficiaries wishing to request to waive the newborn/adoptee enrollment requirement within 60 days of birth or adoption.

1. Download the form by clicking on the above.
2. Print one copy of the form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail or fax one completed copy to the address/number on the form, retain a copy your records.

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Request for Retroactive Enrollment Form  
Used by beneficiaries - qualifying for case management - to request retroactive enrollment in TRICARE Prime for themselves and/or a family member.

1. Download the form by clicking on the above.
2. Print one copy of the form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Return completed form, along with any additional required materials, to your nearest TRICARE Service Center (TSC).
6. Retain a copy for your records.

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Revocation of Authorization 
Used by beneficiaries to revoke a previous authorization to use or disclose personal health information by HMHS.

1. Download the form by clicking on the above.
2. Print one copy of the form.
3. Read the form instructions carefully.
4. Complete all information requested on the form and sign.
5. Mail one completed copy to the address on the form, retain a copy your records.

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