Tricare East Insurance Form

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We are a non-network recognized provider for Tricare, which means we are eligible to submit claims for patients. In order to submit the claim, we require the following information.

Name *

Date of Birth *

YYYY

Benefits Number (this is found on your military ID) *

Tricare typically covers 6 lactation consults per pregnancy. How many, if any, lactation consults have you already had (that were billed to Tricare) with this baby? *

Currently Tricare only covers the mother for lactation services and does not allow us to bill them for the infant portion of our services. Because of this our policy is for families to pay $100 upfront for initial visits, and $75 upfront for follow-ups for infant assessment (for example: latch, growth, tongue-ties) and we will bill Tricare for the mother portion (for example: milk supply, pumping, breast or nipple care). Should Tricare refuse to pay the claim, or not cover in full, you will be required to pay the remainder. Please type your name to sign below as agreement with our policies: *

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