Tricare South Region Application Form Page 12
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TRICARE
South Region Application
(REQUIRED for verification purposes)
D.
EDUCATION INFORMATION
Educational Institution (include name and complete address)
Degree
From
To
(mm/yy)
(mm/yy)
Undergraduate
Institution:
Address:
City, State, Zip:
Graduate/
Institution:
Medical
School
Address:
City, State, Zip:
Internship
Institution:
Address:
City, State, Zip:
Residency
Institution:
Address:
City, State, Zip:
Fellowship
Institution:
Address:
City, State, Zip:
If you are a foreign medical school graduate, are you certified by the Educational Commission for
Yes
No
Foreign Medical Graduates (ECFMG)?
If answered yes, please include a copy of your certificate.
LPCs and LMHCs ONLY
Are you a TRICARE Certified Mental Health Counselor? (no physician oversight) (TC)
Yes
No
If you are a Licensed Professional Counselor (LPC) or Mental Health Counselor (LMHC), have you
Yes
No
passed the National Clinical Mental Health Counselor Exam (NCMHC) or National Counselor Exam
(NCE)? Supporting Documentation Required
Is the school accredited by the Council for Accreditation of Counseling and Related Education Programs
Yes
No
(CACREP)?
Is the school accredited by regional accreditation? If answered yes, provide name of regional
Yes
No
accreditation ___________________________________________________________ and the
certification date for regional accreditation__________________.
PRR RECRUITING
Page 11 of 18
Revised 8/04; 10/04; 7/05; 9/05; 11/05; 1/06; 4/06; 6/06; 12/06; 3/07; 5/07;
Provider Application 08-15B
12/10; 7/11; 10/11; 11/11; 8/12; 10/12; 11/12; 02/13; 8/13; 2/14; 6/14; 01/15; 08/15
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