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: *
Yes:
No:

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? *

Yes:
No:

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Demographic information

First name* Middle initial Last name* Social Security Number (SSN)(No dashes)* Email address* Date of birth(MM-DD-YYYY)* National Provider Identifier (NPI) : * Telehealth capabilities*
Yes:
No: Medicare number:

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.

Point of contact name : * Point of contact email address:* Point of contact phone (no dashes):* Point of contact street address:* Point of contact apt/suite/other: Point of contact city:* Point of contact ZIP Code:*

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Education information:

Do you possess a master’s or higher level degree from a mental health counseling program of education and training accredited for Mental Health Counseling or Clinical Mental Health Counseling? *
Yes:
No:
Select Master's Program accreditation:

Please select the option that fits your situation:*
I have passed the National Clinical Mental Health Counselor Examination (NCMHCE) or an examination determined by the Director, DHA as equal in scope, intent and content to the NCMHCE. I have passed the National Counselor Examination (NCE). Neither of these options apply to my situation.

Date exam passed (MM-DD-YYYY):*

If you do not meet the requirements to be a TRICARE Certified Mental Health Counselor (TCMHC), you may qualify to be a Supervised Mental Health Counselor (SMHC). A SMHC May only be reimbursed when the following criteria are met:

The TRICARE beneficiary is referred for therapy by a physician; AND
A physician is providing ongoing oversight and supervision of the therapy being provided; AND
The SMHC certifies on each claim for reimbursement that written communication has been made or will be made to the referring physician of the results of the treatment. Such communication will be made at the end of the treatment, or more frequently, as required by the referring physician.

I understand the reimbursement policy detailed here.

Clinical requirements

Have you completed a minimum of two years of post-master’s degree supervised mental health counseling practice that includes a minimum of 3,000 hours of supervised clinical practice and 100 hours of face-to-face supervision, which was:*

Provided by mental health counselors, psychiatrists, clinical psychologists, certified Clinical Social Workers (CSWs), TCMHCs, or Certified Psychiatric Nurse Specialists (CPNS) who are licensed for independent practice in the jurisdiction where practicing and must be practicing within the scope of their licenses
Conducted in a manner that is consistent with the guidelines regarding knowledge, skills, and practice standards for supervision of the American Mental Health Counselors Association (AMHCA)?

Yes:
No:

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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.

Electronic signature (Do not include middle initial):* Attested date:*

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Provider certification application

For TRICARE providers