Health Insurance Portability and Accountability Act (HIPAA) Authorization Form – Beneficiary Verification

Please complete the fields below with your beneficiary information. After we verify your information, you will complete the HIPAA Authorization Form to specify how and with whom CareSource Military & Veterans™ (CSMV) may share your Protected Health Information (PHI).

Secure

First Name:

Last Name:

Beneficiary ID:

Please enter your full 11-digit TRICARE ID Number

Date of Birth:

Medicare Claim Number:

CSMV-TRICARE-M-3934155