Tricare Form - Anchor Psychological And Counseling Services printable pdf download

TRICARE Other Health Insurance (OHI) Questionnaire

Update your Other Health Information at

If you prefer you can fax a completed form to: 1‐888‐237‐6262 or mail a completed form to: TRICARE North, PO Box 870159,

Surfside Beach, SC 29587‐9759.

Section I: Personal Information

TRICARE Sponsor’s Name: ________________________________TRICARE Sponsor’s SSN: ________________________

Section II: OHI Information

Policy Holder’s Name and SSN (if different from above): _____________________________________________________

OHI Company Name: ______________________________________________________ State: _____________________

OHI Phone Number: _______________________________OHI Policy, Group or Plan#: ____________________________

OHI Coverage Effective Date: ____ / _____ / _____ OHI Coverage Termination Date: ____ / _____ / _____

Is the Coverage an HMO/PPO plan? ❑Yes ❑No

Type of Coverage: ❑ Group ❑ Individual ❑ Medicare ❑ Supplemental ❑ Medicaid

Indicate if the policy covers the following: ❑ Pharmacy ❑ Dental ❑ Mental Health ❑ Vision

Please list all individuals covered by this policy, indicating effective or termination dates if different from the date(s) above.

Name Date of Birth Effective Date Termination Date

______________________________ ____ / _____ / _____ ____ / _____ / _____ ____ / _____ / _____

Section III: Authorization

The statements made above are true and correct to the best of my knowledge. I understand that federal laws 18 U.S.C. 287 and 1001 provide

for criminal penalties for submitting knowingly or making any false, fictitious or fraudulent statement or claim in any matter within the

jurisdiction of any department of agency of the United States. I further understand that copies of the laws cited may be obtained from

Uniformed Services legal offices, public libraries and many Health Benefit Advisors.

____________________________________________ _________________ ___________________________

Signature Date Phone Number

PRIVACY ACT 1)

Authority: 5 USC 552a; 10 USC 1079, 1086; 58 FR 45318; 32 CFR 199.7. 2) Purpose: To evaluate for medical care provided by civilian s sources

to Military Health Services System beneficiaries applying for coverage under the TRICARE program. 3) Uses: Information from claims forms an forms and related

documents may be given to the Department of Health and Human Services and/or the Department of Transportation consistent with their statutory

administrative responsibilities under TRICARE; to the Department of Justice for representation of the Secretary of Defense in civil actions; and to Congressional

Offices in response to inquiries made on the request of the person to whom a record pertains. Appropriate disclosures may be made to other federal, state local

and foreign government agencies, private business entities and individual providers of care, on matters relating to entitlement, fraud, program abuse, program

integrity, and civil and criminal litigation related to the operation of the TRICARE program. 4) Disclosure: Voluntary, however, failure to provide information may

result in a delay or denial of claims for medical services, or may result in the TRICARE beneficiary not receiving maximum benefits from their health coverage.

Tricare Form - Anchor Psychological And Counseling Services

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