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TRICARE East Mental Health Initial Request Form

Humana Military uses this nine-page form for initial TRICARE East authorization of behavioral health levels of care: inpatient mental health, detoxification, substance use rehabilitation, trauma and eating disorder treatment, partial hospitalization, intensive outpatient programs, opioid treatment programs and psychological testing. It gathers risk, impairments, mental status, treatment history, screening scores and the discharge and step-down plan.

Who completes it

The behavioral health facility or treating mental health provider completes the whole form, including the referring physician, facility, utilization review and discharge planner contacts, and the eating disorder and substance use sections when they apply.

Submitting and payment

How to submit it
Type it in the fillable fields rather than by hand and submit it through Humana Military provider self-service; fax only if online submission is not possible.
Who pays
Partial hospitalization and intensive outpatient requests list the program days, hours per day and revenue code, and whether half-day PHP or IOP is delivered by virtual health.

Good to know

  • Humana asks that the form be completed in full without referring to other documents, and that handwritten submissions be avoided.
  • Active duty service members need referrals for all elective, non-acute or routine services, so the form asks for the unit or command and the military hospital or clinic referral ID.
  • Screening scores go in a table for the PHQ-9, GAD-7 and PCL-5, with dates, and past treatment history covers the previous 24 months.
  • If services are already completed, check the box and include the medical record for review. Current version XPBB0426-A, April 2026.

Get the official form

Download the current version from the source each time; forms change without notice.

Mental health initial request form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Which levels of care does the TRICARE mental health initial request cover?

Inpatient mental health, inpatient substance use detoxification and rehabilitation, inpatient trauma and eating disorder treatment, mental health and substance use partial hospitalization (full or half day), intensive outpatient programs, office-based and non-office-based opioid treatment programs, and psychological testing.

Can I attach records instead of completing every field?

Humana Military asks that the entire form be completed without referencing additional documents, typed in the fillable fields rather than handwritten. The exception is care already completed, where the provider checks the box and includes the medical record for review.

What does the substance use section of the initial request ask?

Section III asks for each substance with amount, frequency, years of use and date of last use, vital signs, Clinical Opiate Withdrawal Scale (COWS) and CIWA scores, and current and past withdrawal symptoms such as tremors, seizures, delirium, or auditory, visual or tactile disturbances.