PROVIDERS

Select your view:
Current Region: NORTH Select a different region

Provider Certification Forms


To apply for TRICARE® non-network certification, select the category below that applies to you. If you are interested in becoming a Network provider, please call 1-877-TRICARE (1-877-874-2273). Please notify PGBA if or when you are no longer licensed. FAX notification to 1-888-279-3540 or mail to PO Box 870156, Surfside Beach, SC 29587-9756.


Individual Application - This application is to be completed by doctors, dentists, therapists, counselors and nurses

Group Application - This application is to be completed by providers who have two or more individual providers working under a Tax ID Number

Note: If your group or location is already TRICARE-certified and you wish to add a new doctor, select Individual Application (above)

Supplier Application - This application is to be completed by the following type of providers: ambulances, portable x-ray suppliers, durable medical equipment suppliers, and clinical labs

Institutional Application - This application is to be completed by the following type of providers: hospitals, ambulatory surgical centers, skilled nursing facilities, birthing centers, hospice and home health agencies

 

Corporate Service Provider Application- This application is to be completed by the following type of providers:radiation therapy, cardiac catheterization clinics, freestanding sleep disorder diagnostic centers, independent physiological laboratories, freestanding kidney dialysis centers, freestanding MRI centers, comprehensive outpatient rehabilitation facilities, freestanding bone marrow transplant centers, diabetic self management education program (ADA Accredited)

 

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

 

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

 


Use the Taxonomy Codes when completing TRICARE Network Provider Applications as well as other healthcare provider documents. If your specialty does not appear, please visit http://www.cms.hhs.gov/ for more information.


BACK