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North Region Forms

Application for Residental Treatment Facility Placement

This form must be filled out by you (the parent or legal guardian) in order to have your child placed in a Residential Treatment Center. Fax the application to Health Net at 1-877-809-8667. You can also have your doctor send the form for you. Health Net will look at the request once we receive both your family application and your doctor application.

Appointment of Appeal Representative

This form is used when a beneficiary chooses to appoint a representative to appeal claims or authorizations on his or her behalf. This form should be submitted with the appeal. However, if you do not submit this form with the appeal you may fax the form to 1-888-881-3622 or mail it to: 

Health Net Federal Services, LLC
P.O. Box 105087
Atlanta, GA 30348-5087

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 Retired Reserve 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

Grievance Form

This document is used to send in a written complaint or concern about issues that cannot be appealed, such as access to care or quality of care. The grievance may be against any member of your health care team, including your TRICARE doctor, Health Net or a Health Net subcontractor.

For grievances regarding a provider or services by Health Net, return the form to:

Health Net Federal Services, LLC
Attn: Grievances
P.O. Box 105338
Atlanta, GA 30348-5338
Fax: 1-888-317-6155

For claims-related issues, do not use this form, contact PGBA.

Phone: 1-877-TRICARE (1-877-874-2273)
Online: www.mytricare.com
Mail: PGBA-Claims Correspondence
P.O. Box 870141
Surfside Beach, SC 29587-9741

Other Health Insurance Questionnaire

Complete this form to notify Health Net Federal Serivces if you have other health insurance. When you do, TRICARE is the second payer. Send the completed for to:

TRICARE North - OHI Questionnaires
P.O. Box 870159
Surfside Beach, SC 29587-9759

Request to Restrict Protected Health Information

Use this form to add more privacy to your health information if you are facing immediate danger, identity theft or fraud, or you have a specific privacy concern. Submit the completed form to:

Health Net Federal Services, LLC
Privacy Compliance Office
2025 Aerojet Road
Rancho Cordova, CA  95742

Fax: 1-888-745-1545

Last Updated 9/9/2013