Bread Crumbs

South Region Forms

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.

For claims issue, mail this form to:

TRICARE South Region
Claims Appeals
P.O. Box 202002
Florence, SC 29502-2002

For a referral or authorization issue, mail this form to:

Humana Military
Second Level Review/Clinical Appeals
P.O. Box 740044
Louisville, KY 40201-9973

Authorization of Release for General Information

This Authorization to Disclose form is filled out when you, the beneficiary, want to grant another individual or organization access to your protected health information (PHI).

Return completed form (select best option):

Humana Military
HMHS Privacy Office
P.O. Box 740062
Louisville, Kentucky 40201-7462

Or fax to: 1-877-298-3407

Authorization for Release of Sensitive Information

The MCSC Operations Manual and state/federal law commonly state that information related to alcohol/drug treatment, abortion, venereal disease, and/or AIDS cannot be disclosed without written consent of the patient/beneficiary. In some instances, information related to mental health and pregnancy/birth control may also require written consent of the patient/beneficiary.)

Humana Military will follow all Federal and state laws and regulations that are more stringent. Return completed form to Humana Military.

Humana Military Privacy Office
P.O. Box 740062
Louisville, Kentucky 40201-7462

Or fax to: 877-298-3407

Automatic Credit/Debit Card Charge

Use this form to establish automatic payments on your debit or credit card for TRICARE Prime enrollment fees or monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult. Submit this completed form to:

Humana Military
P.O. Box 105838
Atlanta, GA 30348-5838

Fax: 1-866-836-9535

Enrollment Fee Allotment Authorization

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

This form is completed online.

Lock Out Waiver Request Form

To request the waiver of the 12-month TRICARE Enrollment Lockout Policy, please complete the form below and mail or fax the completed form to:

Humana Military - TRICARE South
ATTN: PNC
1669 Phoenix Parkway, Suite 210
Atlanta, GA 30349

Fax: 1-866-836-9535

Monthly Automatic Electronic Funds Transfer from Checking or Savings Account

Use this form to set up automatic payments for TRICARE Prime enrolllment fees or monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult using an electronic funds transfer.

This form is completed online.

Newborn/Adoptee Waiver Request Form

Use this form if you want to waive the Prime/TRICARE Prime Remote for Active Duty Family Members (TPRADFM) Enrollment Requirement, within 60 days of birth or adoption.

Mail or Fax the completed form to:

Humana Military
TRICARE South
P.O. Box 740061
Louisville, KY 40201-7461

Fax: 1-866-836-9535

Other Health Insurance Questionnaire

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

Submit the form to:

Humana Military
P.O. Box 740061
Louisville, KY 40201-7461

Fax: 1-866-836-9535

Revocation of Authorization

Use this form to revoke previous authorization to the use or disclosure of my personal health information by Humana Military. Please return completed form to:

Humana Military
HMHS Privacy Office
P.O. Box 740062
Louisville, Kentucky 40201-7462

Fax: 1- 877-298-3407

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

Use this form to request reconsideration of TRS involuntary disenrollment, late initial enrollment, or late change to coverage due to qualifying life event, please complete the request below and mail or fax to:

Humana Military
ATTN: PNC Bank
P.O. Box 105389
Atlanta, GA 30348-5389

Fax: 1-866-836-9535

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

Use this form to request reconsideration of TRR involuntary disenrollment, late initial enrollment, or late change to coverage due to qualifying life event, please complete the request below and mail or fax to:

Humana Military
ATTN: PNC Bank
P.O. Box 105389
Atlanta, GA 30348-5389

Fax: 1-866-836-9535

TRICARE Young Adult Request for TRICARE Regional Office Reconsideration of Involuntary Disenrollment and Late Initial Enrollment

Use this form to request reconsideration of TYA involuntary disenrollment or late initial enrollment, please complete the request below and mail or fax to:

Humana Military
ATTN: PNC Bank
P.O. Box 538025
Atlanta GA 30353-8025

Fax: 1-877-371-6661

Last Updated 3/31/2014