Patient Administration Form

Beneficiary Full Name(Required)

Case Number

Beneficiary Civilian Address / Domicile(Required)

Beneficiary APO/FPO Address

Sponsor SSN

DoD Benefits Number (DBN)(Required)

Beneficiary Date of Birth(Required)

Beneficiary Phone (Landline)

Beneficiary Cell Phone(Required)

Beneficiary Email Address(Required)

Tricare Prime: i.e., Active Duty Service Members and most Active Duty Family Members
Tricare Select: i.e., Retired Service Members and their eligible family members, certain Active Duty Family Members

Select Tricare Plan(Required)

Prime

Select

If you have any health insurance other than TRICARE, it is called other health insurance (OHI). TRICARE pays second after any other health insurance plan. If you have OHI, please follow your other health insurance plan's rules for getting care and file claims with them first. If there is an amount your OHI does not cover, you can file a claim with TRICARE for reimbursement. Remember to include an itemized bill or invoice, diagnosis describing why the medical care is needed, and an "Explanation of Benefits" from your OHI. If the Provider is submitting the claim on your behalf, please provide an "Explanation of Benefits" to the hospital so they can submit a TOP Claim for reimbursement of the balance owed by TRICARE. Visit www.tricare.mil/proofofpayment for more information.

Other health insurance (OHI)(Required)

Yes

Name of Other Health Insurance (OHI)(Required)

In accordance with privacy protection regulations this notice informs you of the purpose of the form and how it will be used. Please read it carefully.

I hereby authorize (“Health Care Provider”) to transmit to International SOS Government Services Inc. (“International SOS”) a copy of my full and complete medical records (in particular, but not limited to, my medical history, reports on findings, laboratory results, ultrasound/MRI/CT/X-ray images, doctors' letters and the entire nursing documentation) including data concerning my health (Art. 4 (15) EU General Data Protection Regulation (GDPR)) and other personal data (Art. 4 (1) GDPR, (“Medical Records”)) for the purposes of the ongoing care, medical management, processing of my medical related claims, any post-payment reviews and the fulfilment of signature on file requirements by International SOS (“Purposes”). For these Purposes only, International SOS may pass on my Medical Records to the following recipients:

TOP Claims Processor, Wisconsin Physician Services (WPS) Insurance Corporation as well as referring U.S. Military Treatment Facility (MTF) or MTF where I am enrolled (if applicable)

Limited to the aforementioned transmission of my Medical Records, I release my treating physicians from their doctor-patient confidentiality.

Signature(Required)

Date of Signature(Required)

PATIENT / AUTHORIZED PERSON

I understand that:
a. This authorization is voluntary.
b. I have the right to revoke this authorization at any time. In case of my revocation, no further exchange of Medical Records will happen between the Health Care Provider and International SOS. This revocation must be addressed to the Health Care Provider. My revocation is only applicable from the moment that I am issuing it. I know it does not apply retroactively. I am aware that the transfer of my Medical Records up until that moment remains lawful.
c. I have a right to inspect and receive a copy of my Medical Records to be used or disclosed.
d. For the European Union and European Economic Area, this consent acts in accordance with the EU General Data Protection Regulation (GDPR), specifically, Art 6 (1) Sentence 1 lit. a GDPR, Art. 9 (2) lit. a GDPR. I am aware that when my Medical Records are transferred to the United States for the previously defined Purposes, that there are possible privacy risks of such a transfer due to the absence of an inter-government framework identifying appropriate safeguards when transferring information from the European Union to the United States.
e. I can find more information about the Health Care Provider's data processing in the Health Care Provider's privacy policy.
f. For the above purposes and the associated measures, the release of medical records is an exception to the doctor-patient confidentiality.