Bread Crumbs

West Region Fee and Payment Forms

The following forms are used to establish recurring payments, make one-time credit card payments and request refunds when needed with UnitedHealthcare. 

Upon completion, all of these forms are can be mailed or faxed to UnitedHealthcare at:

UnitedHealthcare Military & Veterans
TRICARE West Region Enrollment Department
P.O. Box 105492
Atlanta, GA 30348-5492

Fax: 1-877-890-7297

Electronic Payment Authorization Form

Use this form to start, change or stop a recurring electronic payment via funds transfer or credit card with UnitedHealthcare for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premiums. You'll also use this form to make your initial payment with you first enroll (with check or credit card).

Enrollment Fee Allotment Authorization

Use this form to start, change or stop a monthly allotment to UnitedHealthcare from my military retirement pay for TRICARE Prime enrollment fees. You will also complete this form to transfer your allotment from the North or South regions to the West Region.

One-Time Credit Card Payment Form

This form is used to submit a one-time credit card payment for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premium payments. No information will be saved for future payments when using this form.

Refund Request Form for Beneficiary Fees/Premiums

Use this form to request a refund for TRICARE Prime enrollment fees or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult monthly premiums. Refunds are only granted due to life-changing events (i.e. active duty orders, death, etc.) and supporting documentation is required. Refund requests may take four to six weeks for processing.

Last Updated 9/3/2013