PROVIDERS

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Individual Applications


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Applied Behavior Analyst Application

 

Physical, Speech, Occupational, Respiratory Therapist, Audiologist Application

Clinical Psychologist Application 

 

Physician Assistant Application

Clinical Social Worker Application           

 

Physician and Dentist Application

Marriage, Family and Pastoral Application

 

Psychiatric Nurse Specialist Application 

Mental Health Counselor Application  

 

Registered Dietitian, Nutritionist Application 

Nurse Anesthetist, Anesthesia Assistant Application                

 

RN, LPN, Nurse Midwife, Nurse Practitioner Application

                                     

 

All provider applications should be returned to the following address or fax:

 

TRICARE®
Provider Data Management
P.O. Box 870156
Surfside Beach, SC 29587-9756
FAX:  1-888-279-3540

 


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