Tricare South Region Application Form Page 9
Download a blank fillable Tricare South Region Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Tricare South Region Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19®
TRICARE
South Region Application
PRIMARY PRACTICE LOCATION
C.
Practice Name
Practice Address Line 1 (street address required for referrals)
Practice Address Line 2 (include Suite #)
City
State
Zip
Office Manager Name
Appointment Telephone
Office Fax
Referral Fax
E-mail address for this location
Website for this location
Billing Name (must match tax ID name on file with IRS for the TIN listed below)
Billing Address Line 1
Billing Address Line 2
City
State
Zip
Telephone
Tax Identification Number (TIN)
Your Medicare/UPIN Number
N/A
Designated Primary Address for NPI
NPI for this TIN
Is the NPI the same for SSN and TIN?
yes /
no
A certification signature, from the TIN owner/representative, is required if applicant requests payment to a TIN assigned to
another individual, corporation or partnership to authorize payment to the TIN owner, for TRICARE services rendered by
applicant.
TIN is assigned to another individual or entity
____________________________________________________
Authorization Signature by TIN Owner / Representative
TIN is assigned to applicant
____________________________________________________
Authorization Signature of Applicant
Hours of Operation (provide practice availability each day at this location (e.g. 8 a.m. to 5 p.m.). Include multiple practice
hours (e.g. 8 a.m. to 12 p.m. and 3 p.m. to 7 p.m.):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
From
To
Is this office handicapped accessible?
Yes
No
Is this office accessible to public transportation?
Yes
No
PRR RECRUITING
Page 8 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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business