Tricare beneficiary liability form 2026

1. Click ‘Get Form’ to open the TRICARE Beneficiary Liability Form in the editor.
2. Begin by entering your name in the designated field where it states 'I, ________, the TRICARE beneficiary'.
3. Fill in the date of service for each service you are waiving liability for. Use the format 'Date: ___'.
4. For each service, enter the corresponding service code and estimated billed charge. Repeat this for all services listed on the form.
5. Calculate and input the total estimated billed charges at the end of the section labeled 'TOTAL [ESTIMATED] BILLED CHARGES: ___'.
6. Sign and date the form at the bottom where it states 'TRICARE BENEFICIARY SIGNATURE' and 'DATE _____'.
7. Print your name clearly in the provided space under 'TRICARE BENEFICIARY NAME (PRINTED)'.
8. Complete any additional information required regarding your sponsor's SSN and relationship.
9. Finally, ensure that all provider information is filled out accurately before submitting.

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