Tricare Ohi Questionnaire printable pdf download

Tricare Ohi Questionnaire

PGBA, LLC

TRICARE OTHER HEALTH INSURANCE (OHI) COVERAGE QUESTIONNAIRE

1. General Information

TRICARE Sponsor Name:

TRICARE Sponsor SSN:

Do you or any of your family members have OHI coverage? YES_

NO_

Have you or any of your family members had OHI in the past 12 months? YES __

NO__

If you answered yes to question 1 or 2 above, please complete the remainder of the form (duplicate form for multiple

policies). Regardless of your answers above, please read and sign the form at the bottom and submit the form to the

address below.

2. Current OHI Status - Complete only if you or any of your family members currently have OHI.

Policy Holder Name:

Policy Number:

Name of Carrier:

Carrier's Address and Phone No:

Effective Date:

Expiration Date:

Please indicate type of coverage: HMO/PPO_Single_Group_Private_Medicare_Supplemental_

Medicaid/MediCal __

Other:

Does this coverage have pharmacy benefits?

Yes

Does this coverage have any other benefit riders? __

Yes __

If yes, please indicate which one(s):

Name of

Member ID:

Covered Member:

Date of Birth:

Sex:

Effective:

Expiration: (if

different)

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Tricare Ohi Questionnaire