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<h2><strong>FORMS</strong></h2> <p>For more information, visit:&nbsp;<a href="https://tricare.mil/forms" target="_blank">http://tricare.mil/forms</a>.</p> <h4><strong>Release of Medical Information Forms</strong></h4> <table border="0" style="width: 466pt; color: rgb(68, 68, 68);" width="621"> <tbody> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/beneficiaries/tco-media/documents/Appt-Appeal-Auth-Disclose-Form-Bene:Appointment of Appeal Representation &amp; Authorization to Disclose Information}</span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">This form allows the Defense Health Agency (DHA) and/or International SOS to release information related to your medical treatment, and if necessary, photocopies of any medical records which may be required for adjudication of a claim for TRICARE benefits to a representative of your choosing.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/beneficiaries/tco-media/documents/form-dd2870-dec2016:Authorization to Disclose Information}<br><br></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">This form is to provide the Military Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual’s protected health information.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/beneficiaries/tco-media/documents/ROMIF-English-Aug-2021:Consent for Release of Medical Information Form (ROMIF)}</span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">This form is used to capture the Beneficiary consent to the release of medical information for care received under the TRICARE Overseas contract.</span></p></td> </tr> </tbody> </table> <h4><strong>Enrollment, Disenrollment and Change of Situation Forms</strong></h4> <p>{fontweight=500;notice:*NOTE:*} {notice:Online enrollment through Beneficiary Web Enrollment (BWE) is available for TOP plans on}&nbsp;<a href="https://milconnect.dmdc.osd.mil/" target="_blank">milConnect</a>{notice:.}&nbsp;<a href="https://www.tricare.mil/bwe" target="_blank">Click here</a>&nbsp;{notice:to learn more.}</p> <table border="0" style="width: 466pt; color: rgb(68, 68, 68);" width="621"> <tbody> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="http://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2876-3.pdf" target="_blank">TRICARE Overseas Prime Enrollment, Disenrollment &amp; PCM Change Form (DD Form 2876)</a></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">Details on how to complete the DD Form 2876 can be found {downloaddocs=/beneficiaries/tco-media/documents/How-to-complete-the-DD-Form-2876:here}.</span></p><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">For more information on TRICARE Prime Overseas Enrollment, click&nbsp;</span><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-prime-overseas" target="_blank">here</a>.</span></p><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">For more information on TRICARE Prime Remote Overseas Enrollment, click&nbsp;</span><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-prime-remote-overseas" target="_blank">here</a>.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="http://www.esd.whs.mil/portals/54/documents/dd/forms/dd/dd3043-3.pdf" target="_blank">TRICARE Select Enrollment, Disenrollment, and Change Form (DD Form 3043)</a><br><br></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">For more information on TRICARE Select Overseas Enrollment for Active Duty Family Members (ADFMs), click&nbsp;</span><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-select-overseas-ADFMs" target="_blank">here</a>.</span></p><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">For more information on TRICARE Select Overseas Enrollment for Overseas Retirees, click&nbsp;</span><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-select-retirees" target="_blank">here</a>.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="http://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2947-3.pdf" target="_blank">TRICARE Young Adult Enrollment Form (DD Form 2947)</a></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 236.5pt; height: 42pt;" width="315"><p style="margin: 6pt 0.1in;"><span style="color: rgb(58, 58, 58);">For more information on TRICARE Young Adult Enrollment, click&nbsp;</span><span style="color: black;"><a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-young-adult" target="_blank">here</a>.</span></p></td> </tr> </tbody> </table> <h4><strong>TOP Claims Processor Medical Claim Forms</strong></h4> <table border="0" width="0"> <tbody> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);">{downloaddocs=/beneficiaries/tco-media/documents/overseas_estate_notification:Overseas Estate Notification}</span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 238.5pt; height: 42pt;" width="318"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);">This form is used to notify the TOP Claims Processor that your loved one is now deceased. We regretfully request that the following information be provided so we may update our files accurately.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);"><br>{downloaddocs=/beneficiaries/tco-media/documents/tricareohiquestionnaire01:TRICARE Other Health Insurance Questionnaire}<br><br></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 238.5pt; height: 42pt;" width="318"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);">If you have other health insurance in addition to TRICARE, click&nbsp;<a style="color: rgb(11, 92, 171);" href="https://tricare-overseas.com/BENEFICIARIES/CLAIMS/OTHER-HEALTH-INSURANCE" target="_blank">here</a>&nbsp;to learn more about how to update your OHI and benefits information.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);"><a style="color: rgb(11, 92, 171);" href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2527.pdf" target="_blank">Third-Party Liability (DD Form 2527)</a></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 238.5pt; height: 42pt;" width="318"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);">This form is used to collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties.</span></p></td> </tr> <tr style="height: 42pt;"> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 229.5pt; height: 42pt;" width="306"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);"><a style="color: rgb(11, 92, 171);" href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf" target="_blank">TRICARE DoD/CHAMPUS Claim Form – Patient’s Request for Medical Payment (DD Form 2642)*</a></span></p></td> <td colspan="1" rowspan="1" style="padding: 0.75pt; width: 238.5pt; height: 42pt;" width="318"><p style="margin: 6pt 0.1in;"><span style="font-size: 10pt; color: rgb(68, 68, 68);">º£½ÇÂÒÂ×ÉçÇø filing their own medical claims must use this form to receive reimbursement from the TOP Claims Processor for TRICARE Covered Services.</span></p></td> </tr> </tbody> </table> <h4><strong>TOP Extended Care Health Option (ECHO) Registration Forms</strong></h4> <table border="0" width="0"> <tbody> <tr style="height: 42.0pt;"> <td colspan="1" rowspan="1" width="306" style="width: 229.5pt; padding: .75pt .75pt .75pt .75pt; height: 42.0pt;"><p style="margin-top: 6.0pt; margin-right: .1in; margin-bottom: 6.0pt; margin-left: .1in;">{downloaddocs=/beneficiaries/tco-media/documents/echo-registration-form-june2022:TOP Extended Care Health Option (ECHO) Registration Form}</p></td> <td colspan="1" rowspan="1" width="318" style="width: 238.5pt; padding: .75pt .75pt .75pt .75pt; height: 42.0pt;"><p style="margin-top: 6.0pt; margin-right: .1in; margin-bottom: 6.0pt; margin-left: .1in;">To enroll in the&nbsp;<a href="/beneficiaries/plans-and-programs/special-programs/extended-care-health-option" target="_blank">Extended Care Health Option (ECHO)</a>&nbsp;program, you must complete and submit the following three (3) forms, along with your Exceptional Family Member Program (EFMP) Certification Letter:</p><p style="margin-top: 6.0pt; margin-right: .1in; margin-bottom: 6.0pt; margin-left: .35in;"><span style="font-family: Symbol;">·<span style="font-size: 7pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></span>{downloaddocs=/beneficiaries/tco-media/documents/echo-registration-form-june2022:TOP Extended Care Health Option (ECHO) Registration Form}</p><p style="margin-left: .35in;"><span style="font-family: Symbol;">·<span style="font-size: 7pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></span>{downloaddocs=/beneficiaries/tco-media/documents/dd2792:DD Form 2792: Family Member Medical Summary}</p><p style="margin-top: 6.0pt; margin-right: .1in; margin-bottom: 6.0pt; margin-left: .35in;"><span style="font-family: Symbol;">·<span style="font-size: 7pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></span><a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2792-1.pdf" target="_blank">DD Form 2792-1: Exceptional Family Member Special Education / Early Intervention Summary</a></p><p style="margin-top: 6.0pt; margin-right: .1in; margin-bottom: 6.0pt; margin-left: .1in;">For more information on ECHO Enrollment, click&nbsp;<a href="/beneficiaries/plans-and-programs/special-programs/extended-care-health-option" target="_blank">here</a>.</p></td> </tr> </tbody> </table> <h2><br></h2>