<h2>PROVIDER FORMS</h2>
<p><em>Forms for TRICARE Overseas Program Providers</em></p>
<h4>Claim Forms</h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=9:Claim Development Worksheet}{nomargin=0:}</p>
<p>{marginleft=62:}{fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-english-apr-2020--fillable:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-spanish-apr-2020--fillable:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-french-apr-2020--fillable:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-italian-apr-2020--fillable:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-german-jan-2020-fillable:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-portuguese-apr-2020--fillable:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-japanese-jan-2020:Japanese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-greek-apr-2020--fillable:Greek} | {nomargin:}</p>
<p>{marginleft=62:}{fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-turkish-apr-2020--fillable:Turkish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-korean-jan-2020-fillable:Korean} | {fontsize=15;downloaddocs=/providers/tco-media/documents/cdw-polish-apr-2020--fillable:Polish}{marginbottom=54:}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=5:}{fontweight=400;fontsize=15;downloaddocs=/providers/tco-media/documents/CMS1500_ver02-12:CMS 1500 Claim Form}{marginleft=62;margintop=-27:</p>
<p>U.S. Claim Form for reimbursement to individual provider}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=5:}{fontweight=400;fontsize=15;downloaddocs=/providers/tco-media/documents/UB-04Form:UB-04 Claim Form}{marginleft=62;margintop=-27:</p>
<p>U.S. Claim Form for reimbursement to institutional providers}</p>
<h4>Signature on File Forms</h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:Beneficiary Signature on File: Form for provider to capture beneficiary signature/ consent to submit claims on their behalf}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018-japanese:Japanese}{marginbottom=45:}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=9:Provider Signature on File}{nomargin=0:}</p>
<p>{marginleft=62:}{fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_English_Final:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Arabic_Final:Arabic} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_French_Final:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_German_Final:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Italian_Final:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Korean_Final:Korean} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Polish_Final:Polish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Portuguese_Final:Portuguese} | {marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Spanish_Final:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_Sep_2022_Turkish_Final:Turkish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/Provider_SOF_July_2022_Japanese_Final:Japanese}{marginbottom=45:}</p>
<h4>EFT and EDI Agreement Forms</h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:EDI Agreement Form: Electronic Data Interchange (EDI) Form to register for online claims submission using the Secure Provider Claims Portal}{nomargin=0:}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-ENG-OCT2021:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/edi-enrollment-form--final-january-2020-german:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-SPA-OCT2021:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-ITA-OCT2021:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-FRE-OCT2021:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-POR-OCT2021:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-GRE-OCT2021:Greek} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-TUR-OCT2021:Turkish} | {marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-POL-OCT2021:Polish}{marginbottom=45:}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:EFT Form: Form required to receive electronic fund transfer payments}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-English-FEB2022:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-German-FEB2022:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-Spanish-FEB2022:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-Italian-FEB2022:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-French-FEB2022:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-Portuguese-FEB2022:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-Greek-FEB2022:Greek} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-Turkish-FEB2022:Turkish}{marginbottom=45:}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:EFT Form for Providers Using A Billing Agency: Form required to receive electronic fund transfer payments when a provider uses a billing agency}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-English-FEB2022:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-German-FEB2022:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Spanish-FEB2022:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Italian-FEB2022:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-French-FEB2022:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Portuguese-FEB2022:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Greek-FEB2022:Greek} | {fontsize=15;downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Turkish-FEB2022:Turkish}{marginbottom=45:}</p>
<h4><strong>ACH and Wire Payment Form</strong></h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:ACH and Wire Payment Form: Form to Register to Be Paid Via ACH or Wire Transfers}{nomargin=0:}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/ACH-WPF-SEPT2023:English}{marginbottom=45:}</p>
<h4><strong>W9 Form</strong></h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:W9 Form: Request for Taxpayer Identification Number (TIN) and Certification}{nomargin=0:}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/W9-Form-FEB2022:English}{marginbottom=45:}</p>
<h4>ERA Authorization & Instructions Form</h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=62;margintop=-48:Electronic Remittance Advice (ERA) Authorization & Instructions Form}{nomargin=0:}</p>
<p>{margintop=-22:}{marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-OCT2021:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-German:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Spanish:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Italian:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-French:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Portuguese:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Greek:Greek} <u>|</u>{fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Turkish:Turkish} | {marginleft=30;fontsize=15;downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Polish:Polish}</p>
<h4>Applied Behavior Analysis (ABA) Services Forms*</h4>
<p>{marginleft=14;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{subformstitle;fontweight=400;fontsize=15;downloaddocs=/providers/tco-media/documents/aba-initial-assessment-and-treatment-plan-form---final-april-2020:ABA Initial Assessment and Treatment Plan}</p>
<p>{marginleft=14;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{subformstitle;fontweight=400;fontsize=15;downloaddocs=/providers/tco-media/documents/aba-reassessment-treatment-plan-update-form---final-april-2020-1:ABA Reassessment and Treatment Plan Update}</p>
<p>{marginleft=14;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{subformstitle;fontweight=400;fontsize=15;downloaddocs=/providers/tco-media/documents/aba-discharge-form---final-april-2020:ABA Discharge Form}</p>
<p><em>*Note: All ABA clinical documents should be sent password-protected to the following email address: </em><a href="mailto:mtfreferrallon@internationalsos.com" target="_blank"><em>mtfreferrallon@internationalsos.com</em></a></p>
<h4>Other Forms</h4>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{marginleft=9:Patient Administration Form (PAF)}{nomargin=0:}</p>
<p>{marginleft=62:}{fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-english-paf-may-2023:English} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-german-paf-may-2023:German} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-spanish-paf-sept-2020:Spanish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-polish-paf-sept-2020:Polish} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-portuguese-paf-sept-2020:Portuguese} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-italian-paf-sept-2020:Italian} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-french-paf-sept-2020:French} | {fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-korean-paf-jan-2020:Korean} | {nomargin:}</p>
<p>{marginleft=62:}{fontsize=15;downloaddocs=/providers/tco-media/documents/patient-administration-form-japanese-paf-jan-2020:Japanese}{marginbottom=45:}</p>
<p>{marginleft=14;marginbottom=-10;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{subformstitle;fontsize=15;fontweight=400;downloaddocs=/providers/tco-media/documents/prcivilianpcmpatient-referral-form-feb-2020:Puerto Rico Primary Care Manager Patient Referral Authorization}{marginleft=66.5;margintop=-27: For Puerto Rico PCM ONLY. To authorize specialty services to International SOS.}{marginbottom=45:}</p>