Tricare other health insurance questionnaire 2026

1. Click ‘Get Form’ to open the TRICARE Other Health Insurance Questionnaire in our editor.
2. Begin by indicating whether you or any family members have other health insurance (OHI) coverage. Select 'YES' or 'NO'. If 'YES', proceed to provide detailed OHI information.
3. In the section labeled 'Type of coverage', check all applicable options such as HMO/PPO, Group, Individual, Medicare, Supplemental, Medicaid, or Other.
4. Fill in the policyholder’s name and their Social Security number (SSN) or Department of Defense Benefits Number (DBN).
5. Provide the name of the insurance company along with its address and phone number.
6. Enter the Policy/Group/Plan number and specify both the effective and expiration dates of the policy.
7. Indicate which benefits are provided by checking all that apply: Pharmacy, Dental, Vision, Mental health, Durable medical equipment.
8. List all individuals covered by this policy along with their names, gender, relationship to the policyholder, date of birth, and SSN or DBN. If more space is needed, attach a separate list.
9. Finally, sign the document confirming that all statements are true and correct to your knowledge. Include your relationship to the sponsor and date before submitting.

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