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.

Organization name (DBA):* Organization tax ID:* Organization National Provider Identifier (NPI):*
Organization physical street address (PO box not allowed):* Organization physical apt/suite/other: Organization physical address city:* Organization physical address ZIP Code:* Organization phone # (No dashes):* I do not have a fax number Organization fax #(No dashes):* Is billing address same as physical address?: Yes
Organization billing street address:* Organization billing apt/suite/other: Organization billing address city:* Organization billing address ZIP Code:*

Organization billing phone # (No dashes):* Corporate ownership name:*

Main Hospital Information

Please enter details of the main hospital information below.

Main hospital name:* Main hospital tax ID:* Main hospital NPI:* Main hospital physical street address :* Main hospital physical apt/suite/other : Main hospital physical address city :* Main hospital address ZIP Code:*

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.

Certification Point of Contact(POC) name:* Certification Point of Contact(POC) street address:* Certification Point of Contact(POC) apt/suite/other: Certification Point of Contact(POC) city:* Certification Point of Contact(POC) ZIP Code:* Certification Point of Contact(POC) phone #(No dashes):* Certification Point of Contact(POC) email:* Certification Point of Contact(POC) email:*

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State license/certificate Information:

State license/certificate information

State license classification: State license/certificate number: Effective date (MM-DD-YYYY): Expiration date (MM-DD-YYYY): Note: If License does not expire use 12-31-9999.
Please upload state license. If state does not offer license, please upload supporting documentation stated in comments. Upload license

Any disciplinary action: Yes: No:
The state in which this organization is located does not offer a state license or certificate:(checkbox):

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Other license information:

Medicare certification number

Medicare number: Effective date (MM-DD-YYYY): Upload medicare certificate

National accreditation information

Accreditation # Effective date (MM-DD-YYYY): Expiration date (MM-DD-YYYY): Comments:
Upload accreditation

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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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