Tricare Travel Patient Information Form

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TRICARE TRAVEL PATIENT INFORMATION FORM
TRICARE Regional Office - North
7700 Arlington Blvd Suite 5101
Falls Church, VA 22042
Travel Phone: (866) 307-9749, Option 4
Date:
Travel Fax: (703) 275-6258
PRIME TRAVEL BENEFIT (PTB)
PTB E-mail: dha.northptb@mail.mil
CRSC E-mail: dha.northcrsc@mail.mil
COMBAT-RELATED SPECIAL COMPENSATION (CRSC) TRAVEL BENEFIT
Patient Information
Primary Care Manager (PCM) Information
Patient Name:
PCM Name:
Patient Date of Birth:
PCM Address:
PCM City/State:
Patient SSN:
PCM Zip Code:
Patient Address:
PCM Phone:
Patient City/State:
Specialty Care Provider (SCP) Information
Patient Zip Code:
Patient Daytime Phone:
SCP Name:
Patient E-mail:
SCP Address:
SCP City/State:
Military Sponsor's Information
SCP Zip Code:
Sponsor Name:
SCP Phone:
Sponsor SSN:
Type of Specialty:
Sponsor Status:
Medical Appointment Information
USAF
USA
USCG
Branch of Service:
USMC
USN
USPHS
Travel Departure Date:
Non-Medical Attendant (NMA) Information
Travel Return Date:
First Appt Date:
Last Appt Date:
*Please ensure a NMA medical necessity letter from the patient's doctor
accompanies all NMA claims (for ALL adults 18 years or older).
Last Appt Time:
First Appt Time:
*AD members must also have an organizational memo with their claims
First Appt:
AM
PM
Last Appt:
AM
PM
authorizing them to serve as an NMA.
NMA Memo Attached:
YES
NO
Inpatient:
YES
NO
NMA Name:
Admission Date/Time:
NMA SSN:
Discharge Date/Time:
Relation to Patient:
Specialty Care Referral/Authorization Information
NMA Daytime Phone:
Authorization Number:
NMA E-mail:
Civilian (CIV) Govt Employee:
YES
NO
Other Health Insurance (OHI):
YES
NO
Active Duty (AD) Military:
YES
NO
YES
NO
PCM Referral Letter Attached:
Rank/Grade:
NMA Status:
CRSC Required Documents ONLY
AD
Retire
Other
YES
NO
CRSC Determination Letter Attached:
Mode of Travel
Personal Car
Rental Car
PCM Referral Letter Attached:
Air
Other
YES
NO
SCP Provider Treatment
CLAIMANT SIGNATURE:
YES
NO
Confirmation Letter Attached:
By signing you attest that all information provided on this form is accurate and valid.
TRO OFFICE USE ONLY
Date Received
DTOD Distance PCM-SCP
Attestation on File/Category
DTOD Distance HOME-SCP
TRICARE Prime, Standard, TFL
Travel Coordinator
OHI
Completion Date
This document may contain information covered under the Privacy Act, 5 USC 522(a), and/or the Health Insurance Portability and Accountability Act (PL 104-191) and its various
implementing regulations and must be protected in accordance with those provisions.
Revised June 2016

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