Overseas Forms

Authorization to Disclose Information

By filling out this form, you are giving authorization to the TRICARE Overseas Program contractor to release information protected under the Federal Privacy Act. This form is not valid to designate a representative for the Appeals process.

Estate Notification Form

This Form is used to notify TRICARE that your loved one is now deceased. In the instance no legal representative, spouse, next of kin or parent are available to sign the claim, please provide a copy of the probate determination.

Grievance and Complaint Form

Use this form to send a complaint about services you received overseas.

For grievances regarding a provider or services return form to:

International SOS Assistance, Inc.
Reconsideration/Grievances Department
P.O. Box 11570
Philadelphia, PA 19116

For claims-related issues, contact WPS at the following:

Phone: +1 215-942-8393, Option 2 (Claims)
(please visit the website for toll free numbers for your location)

Website: www.tricare-overseas.com

Mail: 
TRICARE Overseas Program
Claims Appeals
P.O. Box 7992
Madison, WI 53707-7992

Other Health Insurance Questionnaire

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

TRICARE Overseas
P.O. Box 7992
Madison, WI 53707-7992 (USA)

Premium Payment Credit Card & EFT Authorization (TRICARE Reserve Select/TRICARE Retired Reserve)

Use this form if you would like to initiate or discontinue a TRICARE Reserve Select or TRICARE Retired Reserve premium payment using your credit/debit card or and electronic fund transfer from your bank account. Forms will be process within 10 days of receipt. Upon receipt of this form International SOS will process all outstanding charges (if any) due for your premium program balance.

Mail or fax a completed copy of page 1 of this form to International SOS.

International SOS Assistance, Inc
Attention: TRS Accounts Receivable
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1 215-354-2340

Additional instructions are found on page 2 of this form.

Premium Payment Credit Card & EFT Authorization (TRICARE Young Adult)

Use this form if you would like to initiate or discontinue a TRICARE Young Adult premium payment using your credit/debit card or and electronic fund transfer from your bank account. Forms will be process within 10 days of receipt. Upon receipt of this form International SOS will process all outstanding charges (if any) due for your TRICARE Young Adult premium program balance.

Mail or fax a completed copy of page 1 of this form to International SOS.

International SOS Assistance, Inc
Attention: TYA Accounts Receivable
PO Box 11689
Philadelphia, PA 19116
Fax: +1 215-354-2340

Additional instructions are found on page 2 of this form.

TRICARE Reserve Select/ TRICARE Retired Reserve Request for TRICARE Regional Office Reconsideration of Involuntary Disenrollment, Late Initial Enrollment and Late Changes to Coverage

Use this form if you would like to request re-enrollment into the TRICARE Reserve Select or Retired Reserve Overseas Program following an involuntary disenrollment, late initial enrollment, or late change to coverage due to qualifying life event. Forms will be sent to the TRICARE Regional Office for review within 10 days of receipt.

Mail or fax a completed copy of page 1 of this form to International SOS

International SOS Assistance, Inc
Attention: TRR Accounts Receivable
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1 215-354-5015

TRICARE Young Adult Request for TRICARE Regional Office Reconsideration of Involuntary Disenrollment, Late Initial Enrollment and Late Changes to Coverage

Use this form if you would like to request re-enrollment into the TRICARE Young Adult Overseas Program following an involuntary disenrollment, late initial enrollment, or late change to coverage due to qualifying life event (QLE). Forms will be sent to the TRICARE Regional Office for review within 10 days of receipt.

Mail or fax a completed copy of page 1 of this form to International SOS

International SOS Assistance, Inc
Attention: TYA Accounts Receivable
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1 215-354-5015

Last Updated 9/3/2013