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.
|Form Name||Tricare Lor Form|
|Form Length||1 pages|
|Avg. time to fill out||15 sec|
|Other names||ICD-9, pre authorization form for tricare, tricare forms for providers, LMHCs|
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)
Patient Name: _____________________________ DOB: ______________ Sponsor #: _________________
Patient Address: ___________________________________________________________________________
City/State: __________________________________________ Phone: ______________________________
Reason for Referral/Disposition: ______________________________________________________________
Print Name of LMHC, LPC, or PC receiving this referral: __________________________________________
The referring physician is providing:
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
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.