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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? *

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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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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
Temporary/Limited


                   Add another practice location





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    National certificate information:
    If your state does not offer licensure, then you must complete this section to qualify for TRICARE certification. Please choose whether you hold or are eligible to hold an ACPE Psychotherapist membership. *


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    Education information:

    Do you have a minimum of a Master’s degree in an appropriate behavioral science field, mental health discipline from an accredited educational institution?*



    Clinical requirements
    Have you completed 200 hours of approved supervision in the practice of pastoral counseling, ordinarily to be completed in a two- to three-year period, of which at least 100 hours were in individual supervision. This supervision occurred preferably with more than one supervisor and included a continuous process of supervision with at least three cases; AND 1,000 hours of clinical experience in the practice of pastoral counseling under approved supervision, involving at least 50 different cases?*




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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?