Self-Referral Form TriWest Condition Management Program
Note: Items marked with * are required fields.
You may also print and complete a
PDF version of this form and fax or mail it to TriWest.
Why Participate in TriWest’s Condition (Disease)
Management Program?
The Condition Management program is free to you as a TRICARE West Region beneficiary. The program focuses on providing you with a
personalized educational plan to help you improve your health management skills while living with a chronic illness such as asthma,
depression, diabetes and/or heart failure. The Condition Management program does not affect your TRICARE benefits in any way.
A TriWest clinical health coach will contact you within 15 business days after receiving your self-referral form to provide a health
assessment and assist you in developing a tailored program based on your personal health goals. Your clinical health coach will also
contact your physician so he/she is aware that you are participating in the program.
For additional details on the Condition Management Program, please contact the Population Health Improvement department at 1-888-259-9378.
Information provided by TriWest Healthcare Alliance is not intended to replace your doctor’s direction and advice; we are here
to support your wellbeing and your physician’s plan of care. If you have specific questions about your condition, please contact
your Primary Care Manager. If you have questions regarding your TRICARE benefits, please visit www.triwest.com or contact TriWest
at 1-888-TRIWEST (874-9378).
Privacy Act Statement - This information is protected under the Privacy
Act of 1974 and shall be handled as "for official use only." Violations may be punishable by fines, imprisonment, or both.
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