Tricare Provider Authorization For Wps Electronic Remittance Advice Form printable pdf download

TRICARE

PROVIDER AUTHORIZATION FOR WPS

ELECTRONIC REMITTANCE ADVICE

Due to privacy regulations, this request must be submitted by the provider’s office or authorized billing agent.

*Check all that apply:

TRICARE West Region______ TRICARE For Life______ TRICARE Overseas______

Please Note: If you are uncertain which contract(s) will be receiving ERA’s, please refer to your TRICARE Provider Handbook which can also be

found at

The only version of electronic remittance available is 5010A1.

ERA PROVIDER INFORMATION

*PROVIDER/FACILITY NAME: _____________________________________________________________

*PROVIDER/FACILITY TAX ID: _____________________________________________________________

Please choose only one option below:

_____

Tax ID

Choose this option if you want all locations under this Tax Id set up for

Electronic Remittance. All Electronic Remits for the Tax ID provided will be sent to the

Receiver ID provided on Page 2.

_____

Specific Group NPI & Pay To/Payment Location(s)

Choose this option for a specific group NPI location(s) and list them below. All Electronic

Remits for the Tax ID and Payment address(s) provided will be sent to the Receiver ID

provided on Page 2. If you have additional locations, please attach. Please include Pay

To/Payment Address.

GROUP NPI

*PAY TO/PAYMENT ADDRESS

1. ______________________ __________________________________________________________________

__________________________________________________________________

2. ______________________ __________________________________________________________________

__________________________________________________________________

3. ______________________ __________________________________________________________________

__________________________________________________________________

4. ______________________ __________________________________________________________________

__________________________________________________________________

If you add an additional Group NPI location in the future and wish to receive ERA for this new location, go to our EDI web site at

and download another form.

*REQUIRED

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Tricare Provider Authorization For Wps Electronic Remittance Advice Form