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Enrollment - TRICARE Select

TRICARE Select Enrollment, Disenrollment and Change Form

Beneficiaries can enroll in or disnenroll from TRICARE Select online through Beneficiary Web Enrollment (BWE) or you can print, complete and mail this form to Health Net Federal Services, LLC for processing.

Tip! You may need to right click on the form link and "save as" to download depending on your browser.

Send completed forms to: 

Health Net Federal Services, LLC
TRICARE Select Enrollment
PO Box 8458
Virginia Beach, VA 23450-8458
Fax: 1-844-388-8282

  • Created: Nov 9, 2021
  • Modified: Nov 9, 2021
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Enrollment Fee Allotment Authorization Letter

TRICARE Select beneficiaries should use this form to start, change or stop automatic deduction of enrollment premiums from their military retirement pay.

  • Created: Feb 2, 2021
  • Modified: Feb 1, 2021
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TRICARE Select Electronic Funds Transfer and Recurring Credit Card Request Form

TRICARE Select beneficiaries should use this form to request automatic monthly payments by electronic funds transfer (EFT) or recurring credit card (RCC).

  • Created: Sep 14, 2020
  • Modified: Sep 14, 2020
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Enrollment Reconsideration Request

Complete this form to request review of disenrollment by Health Net Federal Services.

  • Created: Aug 19, 2021
  • Modified: Aug 19, 2021
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