Tricare Lor Form PDF Details

As a veteran, you may be eligible for Tricare Lor Form. This program provides comprehensive health coverage for veterans and their families. In this article, we'll discuss eligibility requirements and the benefits of Tricare Lor Form. We'll also provide a brief overview of the application process. If you're interested in enrolling in this program, make sure to read our guide carefully.

This table contains information about tricare lor form. Our advice is that you look at this information before you decide to start fiddling with the PDF.

QuestionAnswer
Form NameTricare Lor Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesICD-9, pre authorization form for tricare, tricare forms for providers, LMHCs

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 fax to (803) 462-3990. 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 6010.54M, Chapter 11, Section 3.1, 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: __________________________________________________________________________

City: _____________________________ State: __________________ Phone #: ______________________

Signature: _________________________________________________ Date: _________________________

This form is provided as a resource for optional use.

12/2005

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