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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: *

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? *

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

                   Add another practice location

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    Education information:

    Please select the option that fits your situation:*

    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)?

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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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