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General


Form Name Filetype Revision
An Important Message from TRICARE 02/2008
Electronic Remittance Advice 05/2007
Other Health Insurance Form (OHI) 01/2007
Other Health Insurance Form (OHI) (Spanish) 01/2005
Third Party Liability Form 10/2004
TriWest Provider EDI Agreement Form 05/2007
Waiver of Non-Covered Services 01/2007
Waiver of Non-Covered Services - Sample 01/2008

Medical/Surgical Referral/Authorization


Form Name Filetype Revision
TRICARE Patient Referral/Authorization Form 08/2007
TRICARE Patient Referral/Authorization Form - Sample 04/2008

Behavioral Health


Form Name Filetype Revision
Inpatient Emergency Admission - Detox 01/2008
Inpatient Emergency Admission - Mental Health 01/2008
PCM Communication Form 03/2007
Preauthorization for Electroconvulsive Therapy (ECT) 01/2007
Preauthorization for Inpatient Substance Abuse Rehabilitation 01/2008
Preauthorization for Outpatient Treatment Request 01/2008
Preauthorization for Partial Hospitalization 01/2008
Preauthorization for Psychological/Neuropsychological Testing 01/2007
Residential Treatment Center (RTC) Application 01/2008

Certification


Form Name Filetype Revision
Allied Provider Certification 12/2006
Ambulance Certification 12/2006
Certified Nurse Midwife Certification 12/2006
Certified Psych Nurse Specialist Certification 12/2006
Clinic or Group Practice Certification 12/2006
Clinical Psychologist Certification 12/2006
Clinical Social Worker Certification 12/2006
DME Certification 12/2006
Home Health Certification 12/2006
Independent Lab Certification 01/2007
Individual Physician Certification 12/2006
Institutional Certification 12/2006
Marriage and Family Therapist Certification 12/2006
Mental Health Counselor Certification 12/2006
Pastoral Counselor Certification 12/2006
Pharmacy Non-Retail Certification 12/2006
Physician Assistant Certification 12/2006
Physiological Lab Certification 12/2006
Skilled Nursing Facility Certification 12/2006

Clinical Programs


Form Name Filetype Revision
Applied Behavioral Analysis 10/2005
Cancer Clinical Trials Patient Authorization Form 04/2008
Case Management Referral Form 01/2007
Condition Management Notification Form 05/2007
Qualifying Condition Determination for ECHO-Referral 01/2005
Quality Management (QM) Potential Quality Issue (PQI) Referral 05/2004
Referral for TRICARE 1:1:1 Program 06/2008

Clinical Information



Dental Filetype Revision
Hospital Charges for Non-Adjunctive Dental Care 01/2008
Iatrogenic Dental Trauma Treatment 01/2008
Oral Surgery/Orthodontia 01/2008
Temporomandibular Joint Dysfunction Treatment 01/2008

Injectable Medications Filetype Revision
Injectable Medications 01/2008
Synagis 01/2008
Xolair 01/2008

Medical Equipment/Supplies Filetype Revision
C-leg Microprocessor Lower Limb Prosthesis 01/2008
Insulin Pump 01/2008
Wheeled Mobility 01/2008

Therapies Filetype Revision
Nutritional Therapy 01/2008
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