Physician Referral Form for TRICARE beneficiaries accessing care with Licensed Mental Health
Counselors, Licensed Professional Counselors, or Pastoral Counselors.

Instructions:
Please submit this completed form with initial claim for TRICARE patient indicated or
Fax to (803) 462-3990. Continued physician oversight must be indicated on all subsequent
claims. For Claims Payment Purposes Only - - Do Not Fax To ValueOptions.

Patient Name: _____________________________ DOB: ______________ Sponsor #: _________________
Patient Address: ___________________________________________________________________________
City/State: __________________________________________ Phone: ______________________________
Reason for Referral/Disposition: ______________________________________________________________

ICD-9/DSM-IV Diagnosis: __________________________________________________________________
Print Name of LMHC, LPC, or PC receiving this referral: __________________________________________
The referring physician is providing:
REFERRAL ONLY:

 
REFERRAL AND OVERSIGHT/SUPERVISION:

Please Note: TRICARE Policy Manual 6010.54M, Chapter 11, Section 3.1, states that in order for Mental Health Counselors
(LMHCs and LPCs), and Pastoral Counselors (PCs) to be considered for benefits on a fee-for-service basis by TRICARE, the
beneficiary/patient must be evaluated by a physician who provides a diagnosis and referral to the LMHC, LPC, or PC, prior to the start
of treatment. A physician must also provide continued and ongoing oversight and supervision of treatment. Oversight and
supervision documentation must be submitted with claims. Failure to follow this requirement may result in non-payment.
Beneficiaries will be held harmless. It is the responsibility of the civilian provider (not the beneficiary) to ensure referral and
oversight is obtained. Frequently military physicians elect not to provide the required referral and oversight, or may be willing to
submit a referral but not provide ongoing oversight. ValueOptions may be able to assist with finding a civilian physician in these
cases.

Referring Physician Information:

Print Name: ______________________________________ Is the Physician a PCM? _____ YES _____ NO
Practice Location: __________________________________________________________________________
City: _____________________________ State: __________________ Phone #: ______________________
Signature: _________________________________________________ Date: _________________________

This form is provided as a resource for optional use.
08/31/06