Healthcare MM Packet Tricare Form

HEALTHCARE MM PACKET TRICARE FORM

Patient Name:    Medical Record / TRICARE ID:

Patient Information

Date of Birth: / /    Gender: Male Female Other

Emergency Contact

Insurance / TRICARE Information

TRICARE Prime TRICARE Select Other:

Medical History

Request / Treatment Details

Name of treating facility or clinic:

Proposed Procedure / Service:    Requested Date (if scheduled):

Consent to Treat, Billing & Assignment

By signing below, I authorize the treating providers and affiliated personnel to provide and coordinate medical treatment as necessary for the condition described above. I understand that treatment may include diagnostic tests, medications, and procedures clinically indicated by the treating provider. I acknowledge that no guarantee of specific results has been made.

I authorize the release of medical information necessary to process claims to TRICARE, the Department of Defense, and third-party payers. I hereby assign benefits payable for services furnished to me to the treating provider and authorize payment directly to the provider of insurance benefits otherwise payable to me for these services. This assignment remains effective until revoked in writing, except to the extent that action has been taken in reliance upon it.

Initial to indicate acceptance of the above statements:

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights regarding the privacy of my protected health information (PHI). I authorize the disclosure of my PHI as necessary to process TRICARE claims, coordinate care, and for quality assurance, case management, or utilization review.

Scope of information to be released (check all that apply):
Complete medical record Laboratory and imaging reports Behavioral health records (if applicable) Substance use treatment records (subject to special protections)

This authorization expires on:    I understand that I may revoke this authorization at any time by providing written notice, but revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

Provider / Requesting Clinician Information (to be completed by provider)

Certifications and Legal Notices

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly making a false statement or misrepresenting facts to obtain payment may be subject to penalties under federal law. I authorize the release of information to the extent necessary to determine eligibility, claim payment, and review medical necessity for services.

I further understand that certain records (for example, psychotherapy notes, substance use treatment records) may require an additional specific authorization for release. If such records are requested, I will be specifically notified and my separate written consent will be required unless otherwise permitted by law.

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