Specialty

ABA Providers Doula / Lactation Mental Health and/or Substance Abuse

Business/Group Name

TIN/EIN

Group NPI

Address 1

Address 2

City

County

State

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Zip Code

Fax

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Are you a current TRICARE Network Provider?

Yes No

Are services delivered in-person (home/office), virtual/telemedicine, or both?

In-person (office/homevisit) Virtual/Telehealth Both

Contact Information

Name

Email

Phone

( ) - Extension

Are you considered a physician group for a specific Facility or Hospital?

Yes No

Facility/Hospital Name

Facility/Hospital TIN

Are you affiliated with an independent practice association (IPA), physician-hospital organization (PHO), or management services organization (MSO)?

Yes No

IPA/PHO/MSO Name

IPA/PHO/MSO Contact/Email

Are you currently providing Telemental Health (TMH) services?

Yes No

Do you have the capacity to provide Telemental Health services?

Yes No

Areas of Expertise

So that we can make the most appropriate referrals for care, please check the specialties listed below that best represent your area(s) of expertise:

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If you are a TRICARE network provider, you are not required to complete this form. To add professionals to your contract, please do so through provider self-service.

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