Hf0917x065 2025

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4.8 out of 5

51 votes

The document is an Outpatient Request Form for submitting requests related to various medical services under TRICARE, a health care program. It outlines the submission process, clinical priorities for service requests, and required information about the requesting provider, patient details, servicing provider, and requested services. The form emphasizes confidentiality and includes instructions for urgent requests.

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Click ‘Get Form’ to open the hf0917x065 in the editor.
Begin by filling out the 'Requesting Provider Information' section. Enter your specialty, telephone number, fax number, and NPI #. Ensure all fields are completed accurately.
In the 'Essential Service Information' section, indicate if this is a continuation of services by selecting 'Yes' or 'No'. Provide the date of service and any necessary clinical justification for urgent requests.
Complete the 'Patient Information' section with the sponsor's SSN/DOD benefits number, patient name, date of birth, address, and home phone number.
Fill out the 'Servicing Provider Information' with applicable details including specialty, provider name, NPI, and contact information.
In the 'Requested Service Information', detail each service requested along with diagnosis codes and descriptions. Specify if items are for purchase or rental.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (51 Votes)
2016	3.6 Satisfied (32 Votes)

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