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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 policy(32 CFR 199.6) states that individual health care professionals who are allowed to render health care services only under direct and ongoing supervision as training to be credited towards earning a clinical academic degree or other clinical credential required for the individual to practice independently are excluded from TRICARE participation for the duration of such training.
Are you in an educational or training program required for your provider type?
*

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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:

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Available session settings


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

Hours of operation
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Location and state license/certificate information
This only needs to be filled out for states that require licenses to practice


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    National certificate information:




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      Education information:



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      Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR):



      Please include the front and back of BLS/ CPR card / certificate if applicable.




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          Criminal History Background Check (CHBC):
          TRICARE policy requires that a criminal history background check(CHBC) of assistant behavior analysts must be submitted prior to being certified. The CHBC shall include current federal, state and county criminal and sex offender reports for all locations at which the Assistant Behavior Analyst has resided or worked during the previous 10 years. The CHBC must have been completed within the previous 180 days.

          Do you have a CHBC?

          Does your CHBC indicate that you have been convicted of any felony or a misdemeanor crime against a child or involving domestic violence?


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            Attestation:
            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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             Have questions?