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Provider certification application

Conflict of interest statement

For TRICARE providers

Federal Law (5 U.S.C. 5536) prohibits medical personnel, who are Active Duty Service Members (ADSM) or civilian employees of the government, compensation above their normal pay and allowances for medical care rendered. This prohibition applies to TRICARE benefits whether the claim for reimbursement is filed by the individual who provided the care, the facility in which the care was rendered, or by the sponsor/beneficiary. Claims for TRICARE benefits will be denied in any situation where either a uniform member or civilian employee of the uniform services has the opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries to one or more providers on a selective basis.
Please continue to notify us of any changes related to your provider file information (name, address, specialty, tax number, group affiliations, etc.).
Are you employed by the US Government: *

TRICARE Reimbursement Manual (TRM) Ch 1 Sec 18; 32 CFR 199.6 states providers employed or under a contract which provides for payment to the individual professional provider by an institutional provider cannot be considered. Employees reimbursed by the hospital/institution are not eligible for separate reimbursement outside the realm of the hospital.
Are you hospital-salaried/employed? *

TRICARE Reimbursement Manual (TRM) Ch 13 Sec 1; 32 CFR 199.2; 199.6 (c) states physicians-in-training, interns, residents, and fellows participating in approved postgraduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital or other institutional provider setting, (e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools) are not eligible to be individually certified in these statuses.
Do you fit into one of the outlined categories? *

Demographic information

Correspondence/point of contact information
Identify the person available to answer questions about this TRICARE certification application and the address where you would like to receive correspondence related to your application.

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Location and state license/certificate information:


Please note a fax number must be entered to be listed in the directory
I do not have a fax number

Hours of operation
Location and state license/certificate information

    For the purpose of TRICARE, physician assistants must be employed and supervised by a physician. Private practice is not acceptable. For additional certification information, refer to the TRICARE Policy Manual (TPM), Chapter 11, Section 3.13.

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    National certificate information:

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    Education information:

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    I confirm that the above information is true and complete to the best of my knowledge by typing my name in the box below.

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