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North Region Fee and Payment Forms

Electronic Funds Transfer/Recurring Credit Card Request (TRICARE Prime)

Use this form to request TRICARE Prime automatic monthly payments by electronic funds transfer (EFT) or recurring credit card (RCC).

For New Enrollments, include this request with the Enrollment Form. Please complete, sign, and mail this form and payment to:

Health Net Federal Serivces, LLC
P.O. Box 105146
Atlanta, GA 30348-5146
Fax: 1-888-299-4114

For Existing Enrollments, include this request with your billing statement coupon. Please complete, sign, and mail this form and payment to:

Health Net Federal Services, LLC
P.O. Box 7247-0117
Philadelphia, PA 19170-0117

Electronic Funds Transfer/Recurring Credit Card Request (TRICARE Reserve Select/TRICARE Retired Reserve)

Use this form to request TRICARE Reserve Select or TRICARE Reserve Select automatic monthly payments by electronic funds transfer (EFT) or recurring credit card (RCC).

For New Enrollments, include this request with the Enrollment Form. Please complete, sign, and mail this form and payment to:

Health Net Federal Services, LLC
P.O. Box 105402
Atlanta, GA 30348-5402
Fax: 1-888-299-4114

For Existing Enrollments, include this request with your billing statement coupon. Please complete, sign, and mail this form and payment to:

Health Net Federal Serivces, LLC
P.O. Box 0892
Carol Stream, IL 60132

Electronic Funds Transfer/Recurring Credit Card Request (TRICARE Young Adult)

Use this form to initiate, change or cancel an electronic payment method for TRICARE Young Adult monthly premiums. Please submit this completed form and voided check or deposit slip (if choosing EFT). Submit the completed form to the TRICARE Service Center or mail to the following address:

Health Net Federal Services, LLC
P.O. Box 105425
Atlanta, GA 30348-5425

Fax: 1-888-745-1550

Enrollment Fee Allotment Authorization Letter

TRICARE Prime beneficiaries should use this form to start, change or stop automatic deduction of enrollment fees from their military retirement pay.

For New Enrollments, include this request with the Enrollment Form. Please complete, sign, and mail this form and payment to:

Health Net Federal Services, LLC
P.O. Box 105146
Atlanta, GA 30348-5146
Fax: 1-888-299-4114

For Existing Enrollments, include this request with your billing statement coupon. Please complete, sign, and mail this form and payment to:

Health Net Federal Services, LLC
P.O. Box 7247-0117
Philadelphia, PA 19170-0117

Last Updated 9/3/2013