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TRICARE OVERSEAS PROGRAM CLAIM DEVELOPMENT WORKSHEET Instructions for Reimbursement of Medical Expenses This Claim Development Worksheet must be completed in full by the health care provider signed by both the patient beneficiary and provider and sent with an accompanying itemized invoice to the address indicated on your authorization in accordance with the timely filing requirements of the TRICARE Overseas Program visit www. tricare-overseas. com/contactus for claims address information. 1. Patient Details Authorization Number Name Date of Birth First YYYYMMDD Initial Last Address Gender Sponsor SSN or DBN Sponsor Name Relationship to Sponsor 2. Patient Signature Male Female Date YYYYMMDD Required by Non-Institutional Providers Only SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES THE INFORMATION PROVIDED IN PART ONE IS CORRECT AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION NECESSARY FOR CLAIMS PROCESSING* 3. Diagnosis Describe condition for which the patient received treatment supplies or medication If you know the appropriate diagnosis code ICD-9 or ICD-10 please enter it here Otherwise please write a description of the patient s diagnosis here 4. Emergency Room / Emergency Care 5. Patient Account Number Yes No Enter Provider s patient account number or invoice number here. This will assist in reconciling claim payments to your provider records. 6. Other Health Insurance Does the Patient have other health insurance Name of the other health insurance If yes please note that TRICARE is always the secondary health insurance. Please submit claims to the other health insurance before claiming from TRICARE* Name of the insured party Other health insurance policy number Amount paid by other health insurance 7. Beneficiary Payments If the Beneficiary has paid any amount toward the cost of the health care services rendered please also indicate the total paid by the beneficiary. Amount paid by beneficiary and currency 8. Provider Details 9. Provider Signature If any Third Party Liability cases are in progress this must be clearly indicated* Any Third Parties will pay primary to TRICARE* Reset Form Save Form Print Form. tricare-overseas. com/contactus for claims address information. 1. Patient Details Authorization Number Name Date of Birth First YYYYMMDD Initial Last Address Gender Sponsor SSN or DBN Sponsor Name Relationship to Sponsor 2. Patient Signature Male Female Date YYYYMMDD Required by Non-Institutional Providers Only SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES THE INFORMATION PROVIDED IN PART ONE IS CORRECT AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION NECESSARY FOR CLAIMS PROCESSING* 3. Patient Signature Male Female Date YYYYMMDD Required by Non-Institutional Providers Only SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES THE INFORMATION PROVIDED IN PART ONE IS CORRECT AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION NECESSARY FOR CLAIMS PROCESSING* 3. Diagnosis Describe condition for which the patient received treatment supplies or medication If you know the appropriate diagnosis code ICD-9 or ICD-10 please enter it here Otherwise please write a description of the patient s diagnosis here 4. .

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