Claims

Electronic Funds Transfer (EFT) Authorization Agreement

Use this form to register for, update or terminate an electronic funds transfer (EFT) for the TRICARE West Region. Additional steps may be required. Learn more on our EFT/ERA page.

Email the completed EFT Authorization Agreement to WRVerification@hnfs.com.

• Created: Jan 3, 2025
• Modified: Jan 3, 2025
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Statement of Personal Injury – Possible Third Party Liability

Claims submitted with ICD-10-CM S and T diagnosis codes or ICD-9-CM 800–999 diagnosis codes for professional services exceeding $500 and inpatient services often indicate an accidental injury or illness. When filing these claims, the provider needs to have the beneficiary complete the Possible Third Party Liability form.

Fax form to: 1-844-869-2813

 

Tip: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." 

• Created: May 1, 2025
• Modified: Jul 5, 2022
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Other Health Insurance (2024 claims)

For claims with dates of service prior to Jan. 1, 2025 ONLY:
Use this document to submit beneficiary other health insurance information (OHI).

Do NOT use this form to update 2025 OHI. Instruct beneficiaries to visit to www.tricare.mil/west. 

• Created: May 1, 2025
• Modified: Jan 1, 2025
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