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Provider certification application

Organization information

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.

Satellite of Hospitals (SOH) are extensions of a main hospital and are wholly or partly administered by that hospital. In order to certify a SOH, the main hospital must have active/current TRICARE certification.

Organization information

Missing or invalid information will delay the processing of the certification application, or result in rejection of the application.

I do not have a fax number Yes
Main Hospital Information

Please enter details of the main hospital information below.
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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State license/certificate Information:
State license/certificate information
Note: If License does not expire use 12-31-9999.

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    Other license information:
    Medicare certification or accreditation of main hospital is required. Please enter at least one option below.

    Medicare certification number

      National accreditation information

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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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