Tricare South Region Application Form Page 5
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TRICARE
South Region Application
A.
PROVIDER INFORMATION
Last Name
Suffix
First Name
Middle
Male
Initial
Female
Mailing Address Line 1
Mailing Address Line 2 (include suite #)
City
State
Zip
Telephone
Fax
Social Security Number
NPI for SSN
Date of Birth
Professional Designation
or Title
Correspondence E-mail Address
Website (Professional Web Page)
Current Status:
Active Duty
Active Reservist / NG
Government Employee
VA Employee (other than MDs)
Contracted Military Treatment Facility Employee
None of the above
NOTE: If you are active in one of the above categories, you do not qualify for participation in the TRICARE
network at this time.
U. S. Citizen:
Yes
No
If No, indicate alien registration #: ____________________________
Are you a certified TRICARE provider?
Yes
No
(All providers must become TRICARE certified to be eligible to join the network)
Are you a Medicare participating provider?
Yes
No If yes, see right
Medicare Number
Will you agree to participate with Medicare on a case-by-case basis regarding any
dual-eligible beneficiaries?
Yes
No
All network providers are required to file claims using Electronic Media Claims and receive payment via
Electronic Funds Transfer. Are you able to:
File claims using Electronic Media Claims?
Yes
No
Receive payment via Electronic Funds Transfer?
Yes
No
PRR RECRUITING
Page 4 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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