Tricare Lor Form PDF Details

The Tricare Letter of Referral (LOR) form is an essential document for Tricare beneficiaries who seek access to licensed mental health services. This includes care from Licensed Mental Health Counselors (LMHCs), Licensed Professional Counselors (LPCs), or Pastoral Counselors (PCs). The form requires completion and submission with the initial claim for the patient indicated, and it provides vital information such as the patient's name, date of birth, sponsor number, and reason for referral, including the ICD-9/DSM-IV diagnosis. A significant aspect of the Tricare LOR form is its emphasis on the necessity for a diagnosing physician's referral before the commencement of treatment with LMHCs, LPCs, or PCs. The policy mandates that a physician must not only recommend the patient to mental health counseling but also must maintain ongoing oversight and supervision for the duration of treatment. This directive aims to streamline the care process and ensure that patients receive coordinated and comprehensive mental health services. It is worth noting that non-compliance with these guidelines may lead to non-payment of claims, yet beneficiaries are protected from financial liability. Additionally, the form encompasses the referring physician’s information, including their practice location and contact details, underscoring the collaborative effort required between medical and mental health professionals to meet the policy standards set by TRICARE.

QuestionAnswer
Form NameTricare Lor Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestricare for life forms, PCs, PCM, LMHC

Form Preview Example

Letter Of Referral (LOR)

Physician Referral Form for TRICARE beneficiaries accessing care with Licensed Mental Health Counselors, Licensed Professional Counselors, or Pastoral Counselors

Instructions: Please submit this completed form with initial claim for TRICARE patient indicated. If filing electronically, please call (800) 325-5920 for assistance. Continued physician oversight must be indicated on all subsequent claims.

Patient Name:

DOB:

Sponsor #:

 

 

 

 

 

 

 

 

 

 

 

 

Patient Address:

 

 

City/State:

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Reason for Referral/Disposition:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9/DSM-IV Diagnosis:

Print Name of LMHC, LPC, or PC receiving this referral:

The referring physician is providing:

REFERRAL ONLY:

 

REFERRAL AND OVERSIGHT/SUPERVISION:

 

 

 

 

 

 

 

 

Please Note: TRICARE Policy Manual 6010.47M, Chapter 10, Section 2.1, states that in order for Mental Health Counselors (LMHCs and LPCs), and Pastoral Counselors (PCs) to be considered for benefits on a fee-for-service basis by TRICARE, the beneficiary/patient must be evaluated by a physician who provides a diagnosis and referral to the LMHC, LPC, or PC, prior to the start of treatment. A physician must also provide continued and ongoing oversight and supervision of treatment. Oversight and supervision documentation must be submitted with claims. Failure to follow this requirement may result in non-payment. Beneficiaries will be held harmless.

Referring Physician Information:

 

 

 

 

 

 

 

 

 

 

Print Name: __________________________________

Is the Physician a PCM?

 

YES

 

NO

Practice Location: Berkeley Community Mental Health Center

 

 

 

 

 

Moncks Corner

State:

SC

Phone #:

(843) 761-8282

 

 

 

City: ________________________

 

 

 

 

 

 

 

Signature:

 

 

 

 

Date: _______________________________

This form is provided as a resource for optional use.

How to Edit Tricare Lor Form Online for Free

It is simple to complete the LPC blanks. Our PDF editor makes it practically effortless to work with any type of PDF. Down the page are the primary four steps you should follow:

Step 1: The initial step would be to click the orange "Get Form Now" button.

Step 2: The document editing page is right now available. It's possible to add information or enhance present data.

Create the LPC PDF by typing in the details required for each area.

step 1 to completing tricare forms for providers

Write the necessary particulars in the Referring Physician Information, Print Name Is the Physician a PCM, Practice Location, City State Phone, Signature, Date, and This form is provided as a part.

step 2 to finishing tricare forms for providers

Step 3: Choose the "Done" button. Next, it is possible to export your PDF file - upload it to your device or deliver it via email.

Step 4: Make at least a few copies of the file to keep clear of different potential difficulties.

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