<h2>BENEFICIARY FORMS</h2> <p>{fontweight=500;notice:*NOTE:*} {notice:Online enrollment through Beneficiary Web Enrollment (BWE) is available for TOP plans on} <a href="https://milconnect.dmdc.osd.mil/" target="_blank">milConnect</a>{notice:.} <a href="https://www.tricare.mil/bwe" target="_blank">Click here</a> {notice:to learn more.}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontweight=400;fontsize=15;downloaddocs=/beneficiaries/tco-media/documents/Appt-Appeal-Auth-Disclose-Form-Bene:Appointment of Appeal Representation &amp; Authorization to Disclose Information}{margintop=-25;marginleft=32:</p> <p>This form allows the Defense Health Agency (DHA) and/or International SOS to release information related to your medical treatment, and if necessary, photocopies of any medical records which may be required for adjudication of a claim for TRICARE benefits to a representative of your choosing.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400;downloaddocs=/beneficiaries/tco-media/documents/Form-DD2870-Dec2016:Authorization to Disclose Information}{margintop=-25;marginleft=32:</p> <p>This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontweight=400;fontsize=15;downloaddocs=/beneficiaries/tco-media/documents/ROMIF-English-Aug-2021:Consent for Release of Medical Information Form (ROMIF)}{margintop=-25;marginleft=32:</p> <p>This form is used to capture the Beneficiary consent to the release of medical information for care received under the TRICARE Overseas contract.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400;downloaddocs=/beneficiaries/tco-media/documents/Overseas_Estate_Notification:Overseas Estate Notification}{margintop=-25;marginleft=32:</p> <p>This form is used to notify the TOP Claims Processor that your loved one is now deceased. We regretfully request that the following information be provided so we may update our files accurately.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400:<a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2527.pdf" target="_blank">Third-Party Liability (DD Form 2527)</a>}{margintop=-25;marginleft=32:</p> <p>This form is used to collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400:<a href="http://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2876-3.pdf" target="_blank">TRICARE Overseas Prime Enrollment, Disenrollment &amp; PCM Change Form (DD Form 2876)</a>}{margintop=-25;marginleft=32:</p> <p>For more information on TRICARE Prime Overseas Enrollment, click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-prime-overseas" target="_blank">here</a>.</p> <p>For more information on TRICARE Prime Remote Overseas Enrollment, click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-prime-remote-overseas" target="_blank">here</a>.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400:<a href="http://www.esd.whs.mil/portals/54/documents/dd/forms/dd/dd3043-3.pdf" target="_blank">TRICARE Select Enrollment, Disenrollment, and Change Form (DD Form 3043)</a>}{margintop=-25;marginleft=32:</p> <p>For more information on TRICARE Select Overseas Enrollment for Active Duty Family Members (ADFMs), click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-select-overseas-ADFMs" target="_blank">here</a>.</p> <p>For more information on TRICARE Select Overseas&nbsp;Enrollment for Overseas Retirees, click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-select-retirees" target="_blank">here</a>.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400:<a href="http://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2947-3.pdf" target="_blank">TRICARE Young Adult Enrollment Form (DD Form 2947)</a>}{marginleft=32;margintop=-25:</p> <p>For more information on TRICARE Young Adult Enrollment, click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/tricare-young-adult" target="_blank">here</a>.}{marginbottom=25:}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400:<a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf" target="_blank">TRICARE DoD/CHAMPUS Claim Form - Patient's Request for Medical Payment (DD Form 2642)*</a>}{marginleft=32;margintop=-25:</p> <p>Beneficiaries filing their own medical claims must use this form to receive reimbursement from the TOP Claims Processor for TRICARE Covered Services.}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400;downloaddocs=/beneficiaries/tco-media/documents/TRICAREOHIQuestionnaire01:TRICARE Other Health Insurance Questionnaire}{marginleft=32;margintop=-25:</p> <p>If you have other health insurance in addition to TRICARE, click <a href="https://tricare-overseas.com/BENEFICIARIES/CLAIMS/OTHER-HEALTH-INSURANCE" target="_blank">here</a> to learn more about how to update your OHI and benefits information.}</p> <p>{marginbottom=-11;showimage=/resource/1659101612000/site_images_sample/images/ICON_tricare.PNG:}{formstitle;fontsize=15;fontweight=400;downloaddocs=/beneficiaries/tco-media/documents/ECHO-Registration-Form-OCT2024:TOP Extended Care Health Option (ECHO) Registration Form}</p> <p>{marginleft=32:}To enroll in the {color=#0000ee;fontweight=400;contentlink=/beneficiaries/plans-and-programs/special-programs/extended-care-health-option:Extended Care Health Option (ECHO)} program, you must complete and&nbsp;{formstitle:submit the following three (3) forms, along with your Exceptional Family Member Program (EFMP) Certification Letter:}</p> <p>{marginbottom=60:}</p> <p>{subitemlist:</p> <ul> <li>{fontweight=400;fontsize=13;color=#0077cc;downloaddocs=/beneficiaries/tco-media/documents/ECHO-Registration-Form-OCT2024:<strong>TOP Extended Care Health Option (ECHO) Registration Form</strong>}</li> <li>{fontweight=400;fontsize=13;color=#0000ee: <a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2792.pdf" target="_blank">DD Form 2792: Family Member Medical Summary</a>}</li> <li>{fontweight=400;fontsize=13;color=#0000ee: <a href="https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2792-1.pdf" target="_blank">DD Form 2792-1: Exceptional Family Member Special Education / Early Intervention Summary</a>}}</li> </ul> <p>{marginleft=32;margintop=5;marginbottom=24:For more information on ECHO Enrollment, click <a href="https://tricare-overseas.com/beneficiaries/plans-and-programs/special-programs/extended-care-health-option" target="_blank">here</a>.}{marginbottom=25:}</p> <p>{marginleft=32:}{fontsize=13:For more information, visit: } {color=#0000ee;fontweight=400;fontsize=13:<a href="http://tricare.mil/forms" target="_blank">http://tricare.mil/forms</a>}.</p>