TRICARE PATIENT REFERRAL/AUTHORIZATION FORM Use this form for Medical/Surgical Requests Only Sponsor SSN _____ Sponsor Name Services and medications for which preauthorization may be required for Medicaid, Medicare Advantage, dual Medicare-Medicaid and commercial members. Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 3 of 10 GR-69025-CA (5-17) Aetna complies with applicable Federal civil rights laws and does not discriminate, Patient Referral Authorization Form . TRICARE referrals should be submitted through www.humana-military.com (log on to Self-Service for Providers). Sometimes certain types of specialty care and prescription drugs require special review called prior authorization to make sure they are right for the patient. Modafinil (Provigil) Prior Authorization Criteria for the TRICARE Pharmacy US Family Health Plan Prior Authorization Request Form Find a Form. UnitedHealthcare and TRICARE have made several forms available for download. Select from the Form Category menu below to begin. Submitting Authorization TRICARE Formulary Search Tool NCP attestation form. Self-service. Navigate. Beneficiary Get a summary of TRICARE Referrals and Prior Authorizations information with our handy chart. TRICARE Publications Provider forms; Charts; Forms. Presentations; Patient referral authorization form (Log in to submit request online)
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