Tricare South Region Application Form Page 8

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TRICARE
South Region Application
CLINICAL EXPERTISE SPECIALTIES:
ValueOptions Federal Services intends to make clinically-specific referrals to its various providers. Please select up to
a maximum of five (5) specialties listed below in which you have training and experience. Rank them in order of you
expertise and referral preference (i.e., 1=most preferred; 2=second highest preferred, etc.)
NOTE: Only the first two specialty choices will show in the directory and on the website.
SPECIALTY
CODE
DESCRIPTION
__ PostTraumatic Stress Disorder__ _
st
Example: 1
Choice
___M3____
st
__________
1
choice
_________________________________
nd
__________
2
choice
_________________________________
__________
rd
3
choice
_________________________________
__________
th
4
choice
_________________________________
__________
th
5
choice
____________________________________
CODE
DESCRIPTION
CODE
DESCRIPTION
Adolescent Therapy
ECT
I4
J3
Affective Disorder
Family Therapy/Blended Families
I2
J6
Alcohol/Chemical Dependency
Gay/Lesbian/Bisexual Issues
I3
J9
Anxiety Disorders
Grief/Bereavement
Q4
K8
ASAM Certified Addictionologist
Head Trauma
N8
L4
ADHD
Neuropsychological Testing
I1
L9
Borderline Personality/Traits
Panic/Phobias
I6
M1
Child Therapy
Physical/Sexual Abuse Victims
L2
M9
Chronic Pain
PostTraumatic Stress Disorder
I8
M3
Christian Counseling
Psychological Testing
I7
M5
Critical Incident Stress Debriefing
Schizophrenia
N6
M7
Dissociative Identity Disorders
Separation/Divorce
L8
L6
Eating Disorders
Stress Management
J2
N3
PRR RECRUITING
Page 7 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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