Tricare South Region Application Form

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Tips for Completing the TRICARE South Region Application
To ensure timely processing of your credentialing application, submit a completed and signed
TRICARE South Region Provider Application and copies of all required documents. All
documents must be current. Incomplete applications or application packets with missing or
outdated documents will not be processed.
Note: A red box on the form indicates a required field. You can work on this digital application
in more than one sitting; save to your computer and re-open the file as needed.
Dates: Be sure to input all dates using the format specified, either a 4-digit (MM-YY) or 6-digit
(MM-DD-YY) format. Otherwise, the document will auto-populate to the current year.
Medicare Participation: If you will not agree to participate with Medicare on a case-by-case
basis regarding dual-eligible beneficiaries, you will not be accepted as a TRICARE Network
provider.
Digital Signature: To create a digital signature for use on this and other documents,
click here
to visit Adobe’s Help center. (If the link does not work, visit
and search “Sign PDF.”)
Common areas needing attention: Five areas frequently need additional attention. Please
ensure you have completed the following areas:
• Become TRICARE Certified (Contact PGBA)
• Proof of professional liability coverage
• Complete Practice Information (Section C, Page 8)
• Sign the Attestation/Release (Page 16)
• Complete the Provider Agreement (this is a separate document from the Application)
Use the Check Off Sheet at the end of the application to ensure all required documents and
materials are included.
Questions about the application? Contact the Provider Relations Department at
or (800) 700-8646.
When you have completed the application and gathered all attachments, send them electronically
to
or by secure fax to (866) 429-8995.
If you must submit the application and attachments by mail, print your typed PDF and supporting
documentation and mail to:
ValueOptions Federal Services Credentialing
P.O. Box 551188
Jacksonville, FL 32255-1188
P.O. Box 551188 ♦ Jacksonville, FL 32255-1188
Phone (800) 700-8646
NET: Original 08/14; Rev 09/15
PRR RECRUITING

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