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Forms

 

Accessing TRICARE DD forms:

Due to security settings, you may not be able to view certain DD forms in your web browser. If you encounter an issue viewing a form in your web-browser, right-click and select "Save as" to save to your computer. You can then open the form using your system's default program for viewing PDFs. You can also try accessing the form directly from the official DoD forms site.

Claims Billing and enrollment HIPAA Miscellaneous
Claim forms

Appointment of representative

Claim form (DD2642)

Other Health Insurance (OHI) questionnaire

Public facility use certification form

Timely filing waiver

Third party liability claim form (DD2527)

New claim submissions

For care received starting Jan. 1, 2025:
Humana Military Claims
PO Box 202146
Florence, SC 29502-2146
Fax: 877-489-0007

 

For care received through Dec. 31, 2024
TRICARE EAST
Attn: New Claims
PO Box 7981
Madison, WI 53707-7981
Fax: (608) 327-8522

Third Party Liability (TPL) submissions

For care received starting Jan. 1, 2025:
Humana Military Claims
Attn: Third Party Liability (TPL)
PO Box 202152
Florence, SC 29502-2152.
Fax: (877) 489-0041

 

For care received through Dec. 31, 2024:
TPL form and TPL requested medical record submissions:
TRICARE East Region
Attn: Third Party Liability (TPL)
PO Box 8968 Madison, WI 53707-7539
Fax: (608) 221-7539
Billing and payment options

Make a payment

Set up allotment

Set up recurring payment with bank account

Set up recurring payments with credit card

Log in to see your billing summary or make a payment

Enrollment forms

Continued Health Care Benefit Program (CHCBP)

Prime enrollment, disenrollment and PCM change form (DD2876)

Select enrollment, disenrollment and change form (DD3043)

TRICARE Young Adult (TYA) application (DD2947)
General release of information authorization requests

General release of information authorizations should be completed online through beneficiary self-service. Sensitive diagnosis and revocation options are not available in self-service at this time.

Log in or register to submit a general release of information request.

Paper submission forms

Authorization for release of information form (general)

Authorization for release of information form (sensitive diagnosis)

Revocation of prior authorization
Red Hill

DHA’s Red Hill Public Health information page

Email questions to dha.redhill@health.mil

Miscellaneous forms

Case management referral form
Video call with the doctor from phone
TRICARE resources