Tricare South Region Application Form Page 7
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TRICARE
South Region Application
DESCRIPTION OF PRACTICE:
Percent of
Are You Currently
Percent of
Population
Practice
Accepting New
Modality
Practice
(must equal 100%)
(must equal 100%)
Patients
?
Child (0-12)
%
Yes
No
Inpatient
%
⇒
Adolescent (13–17)
%
Yes
No
Outpatient
%
⇒
Adult (18-64)
%
Yes
No
⇒
Total
0
Geriatric (65+)
%
Yes
No
⇒
Youngest age treated:_______
Oldest age treated: _________
Total
0
Primary language, written and/or spoken, if other than English:
____________________________________________
Identify any foreign language(s) or sign language that you use fluently in treating patients. Select no more than 5
and rank numerically in order of preference. Please indicate if your language choice is written or spoken by placing
W or S or both by your language choice.
____ American Sign Language (SG)
____ Greek (GR)
____ Polish (PL)
____ Arabic (AR)
____ Hebrew (HE)
____ Portuguese (PO)
____ Armenian (AN)
____ Hindi (HI)
____ Russian (RU)
____ Chinese (CH)
____ Hungarian (HU)
____ Spanish (SP)
____ Dutch (DU)
____ Italian (IT)
____ Swedish (SW)
____ Farsi / Persian (FA)
____ Japanese (JA)
____ Tagalog / Filipino (PH)
____ French (FR)
____ Korean (KO)
____ Vietnamese (VI)
____ German (GE)
____ Norwegian (NW)
____ Yiddish (YI)
ALTERNATE PRACTICE COVERAGE: Please list the practitioners covering your practice when you are
unavailable (other than yourself).
Name
Phone
Name
Phone
PRR RECRUITING
Page 6 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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