Military members and their families can receive health insurance coverage through United Healthcare Military. This program offers a range of benefits, including preventive care, outpatient services, mental health and substance abuse treatment, and more. In order to take advantage of these benefits, individuals must complete the United Healthcare Military Form. The form is simple to fill out and can be completed online or through the mail. By completing this form, military members and their families can ensure they have access to the best possible health care coverage.
Listed below are some details about united healthcare military. You may find out its length, the actual time required to fill out the form, the blanks you should fill in, and so forth.
| Question | Answer |
|---|---|
| Form Name | United Healthcare Military |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | united healthcare military veterans tricare referral auth request, uhcmilitarywest com providers referrals, unitedhealthcare military and veterans form, united healthcare military and veterans forms |
TRICARE Service Request/Notification
Fax referral to: UnitedHealthcare Military & Veterans at:
The Military Treatment Facility (MTF) in your area may have Right of First Refusal for this service.
Beneficiary Information
Name: Last |
First |
M.I. |
Gender |
DOB: (mm/dd/yyyy) |
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_____ / _____ / ________ |
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Address: Street |
Apt. No. |
City |
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State |
ZIP Code |
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Contact Phone #: |
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Sponsor SSN: |
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Requesting Provider Information |
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Name:
NPI #:
Address: Street |
City |
State |
ZIP Code |
Contact Name: Last |
First |
Contact’s Department in Facility:
Office Phone #:
Office Fax #:
Provider Rendering Care (Physician/Facility/Agency/Vendor)
Name: (Physician/Facility/Agency/Vendor)
Provider NPI #: (mandatory on form)
Specialty: |
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Reason for |
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Anticipated Date of Service/Admission Date: (mm/dd/yyyy) |
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_____ / _____ / ________ |
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Address: Street |
City |
State |
ZIP Code |
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Office Phone #:
Office Fax #:
Servicing Facility Information
Name:
TIN:
Address: Street |
City |
State |
ZIP Code |
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Request Priority: (Please check one) |
□Routine □Urgent |
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Service Type: (Please check one) |
□ Specialty Referral □ Inpatient (Acute, SNF, RTC or Rehab) |
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□ Outpatient (Medical/Surgical or Behavioral Health) |
□ DME, Home health |
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This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at
TRICARE West Region Customer Service:
TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.
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Doc#: UHC2467w_20130328 |
© 2013 United HealthCare Services, Inc. |
SR#: 10624774 |
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Page 1 of 2 |
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TRICARE Service Request/Notification |
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Admission Type: (Please check one) □ ER |
□ Direct Admit □ Elective |
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Diagnostic Information |
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Diagnosis: |
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Any Secondary Diagnosis: |
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Requested Procedures/Services: |
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CPT 4 Code/ HCPCS Code: |
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Frequency Requested: _____ |
□ Daily |
□ Weekly □ Monthly □ Other |
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Duration: ______ □ Days |
□ Weeks |
□ Months |
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Number of Visits Requested:
If DME: □ Purchase □ Rental
Medical Necessity of Services (Reason for request and/or Explanation of Medical Necessity)
This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at
TRICARE West Region Customer Service:
TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.
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Doc#: UHC2467w_20130328 |
© 2013 United HealthCare Services, Inc. |
SR#: 10624774 |
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Page 2 of 2 |
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