Dd Form 1351-3, Tricare Specialty Care Claim
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1TRICARE SPECIALTY CARE CLAIM
PAGE
OF
PAGES
STATEMENT OF ACTUAL EXPENSES
REIMBURSABLE EXPENSES
LOCAL
DATE
LODGING
LODGING
MEALS (Daily) (Note 2)
FUEL
AIRFARE
OTHER
TRANSPORTATION
20___
(Note 1)
TAXES
(Note 3)
(Note 4)
(Note 6)
(Note 5)
Breakfast
Lunch
Dinner
Total
NOTES
(1)Attach lodging receipt(s) as supporting document(s).
(5) Cost of authorized transportation between residence and specialty
(2)Total actual, daily cost of claimant’s meals and tips (less the cost of
care facility (SCF), and associated travel at destination as necessary
alcoholic beverages) for respective meals.
(including travel between SCF, lodging and terminal sites). Includes rental
(3)Total actual, daily cost of fuel for authorized vehicle use.
car, taxi, shuttle, bus, rail or ferry fees, if authorized.
(4)Total authorized, unreimbursed airfare – attach receipts verifying
(6) Total cost of parking and toll expenses, and other authorized
I,
certify that itemized amounts above, are actual
(Type or Print Name)
and necessary expenses incurred at my expense in performance of official travel for which I have not been reimbursed.
SIGNATURE
DATE
DD FORM 1351‐3, SEP 1997
This form modified August 2011 by TRICARE Regional Office ‐ West
for Specialty Care Claims authorized under the Prime Travel Benefit Program
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