PROVIDERS

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Individual Applications


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Anesthesiologist Application

 

Nutritionist Application

Board Certified Behavior Analyst Application

 

Pastoral Counselor Application 

Clinical Psychologist Application 

 

Physical, Speech, Occupational Therapist, Audiologist Application

Clinical Social Worker Application           

 

Physician Assistant Application

Marriage and Family Therapist Application

                                                          

Physician and Dentist Application

Mental Health Counselor Application  

 

Psychiatric Nurse Specialist Application 

Certified Nurse Midwife Application                

 

Registered Dietitian Application 

Nurse Anesthetist Application

 

RN, LPN, 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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