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Enrollment - TRICARE Select

TRICARE Select Enrollment, Disenrollment and Change Form

Beneficiaries can enroll in or disnenroll from TRICARE Select online through Beneficiary Web Enrollment (BWE) or you can print, complete and mail this form to Health Net Federal Services, LLC for processing.

Send completed forms to: 

Health Net Federal Services, LLC
TRICARE Select Enrollment
PO Box 8458
Virginia Beach, VA 23450-8458
Fax: 1-844-388-8282

  • Created: Jan 22, 2020
  • Modified: Jan 8, 2020
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Enrollment Fee Allotment Authorization Letter

TRICARE Select beneficiaries should use this form to start, change or stop automatic deduction of enrollment premiums from their military retirement pay.

  • Created: Feb 2, 2021
  • Modified: Feb 1, 2021
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TRICARE Select Electronic Funds Transfer and Recurring Credit Card Request Form

TRICARE Select beneficiaries should use this form to request automatic monthly payments by electronic funds transfer (EFT) or recurring credit card (RCC).

  • Created: Sep 14, 2020
  • Modified: Sep 14, 2020
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Enrollment Exception Request

Complete this form to request review of disenrollment by Health Net Federal Services.

  • Created: Jul 13, 2018
  • Modified: Jul 13, 2018
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TRICARE Select Enrollment Reinstatement Form

TRICARE Select Group A retirees and family members who were disenrolled for non-payment can submit this form by June 30, 2021, to request reinstatement and pay fees due. Reinstatement requires automatic payment set up for future fees. 

After June 30, enrollment changes can only be made after a qualifying life event or during TRICARE's annual Open Season.

  • Created: Apr 30, 2021
  • Modified: Apr 30, 2021
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