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Non-Network Provider Forms

Corporate Services Provider Certification Application

This non-network certification application should be used for Corporate Services Providers.

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jul 11, 2019
  • Modified: Jul 11, 2019
  • View »

Group Certification Application

This non-network certification application should be used for groups.

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jul 11, 2019
  • Modified: Jul 11, 2019
  • View »

Individual Provider Certification Applications

These non-network individual provider certification applications should be used for:

  • Anesthesiologist assistants
  • Board Certified Behavior Analysts
  • Certified nurse midwifes
  • Christian Science practitioners
  • Clinical psychologists
  • Clinical social workers
  • Marriage and family therapists
  • Mental health counselors
  • Nurse anesthetists
  • Nutritionists
  • Pastoral counselors
  • Physical therapists, speech therapists, occupational therapists, and audiologists
  • Physicians and dentists
  • Physician Assistants
  • Psychiatric nurse specialists
  • Registered dietitians
  • RNs, LPNs, Nurse Practitioners

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jul 11, 2019
  • Modified: Jul 11, 2019
  • View »

Institutional Certification Applications

These non-network institutional certification applications should be used for:

  • Birthing centers
  • Home Health Agencies
  • Hospice
  • Institutional 
  • Institutional Freestanding Psychiatric and Substance Use Disorder (SUD) Partial Hospitalization Programs (PHP)
  • Institutional Intensive Outpatient Programs (IOP)
  • Institutional Opioid Treatment Programs (OTP)
  • Institutional Residential Treatment Centers (RTC)
  • Institutional Substance Use Disorder Rehabilitation Facilities
  • Skilled Nursing Facilities

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jul 11, 2019
  • Modified: Jul 11, 2019
  • View »

Non-Network Practitioner Affiliation/Disaffiliation Request Form

This form is used to affiliate or disaffiliate a practitioner to a professional service location. If adding a new professional service location, please use the Provider Information Update Request Form. 

Return completed form to:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
  • View »

Non-Network Provider Information Update Request Form

This form is used to update provider information in the TRICARE Non-Network Provider file. This can include updates to your:

  • Tax Identification Number (TIN)
  • Billing or physical address
  • Name
  • National Provider Identifier (NPI)

Return completed form to:

TRICARE West Provider Data Management
P.O. Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Mar 27, 2018
  • Modified: Mar 27, 2018
  • View »

Non-Network Provider Specialty Information Update Request Form

Non-network providers should use this form to update specialty information in the TRICARE West Region non-network provider file. 

Note: If your specialty is mental health, you must complete the appropriate mental health application.

Return completed form to:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jun 13, 2018
  • Modified: Jun 12, 2018
  • View »

Non-Network Provider's Notarized Facsimile or Stamp Signature Authorization

Return completed form to:

TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Dec 30, 2017
  • Modified: Dec 30, 2017
  • View »

Supplier Certification Applications

These non-network supplier certification applications should be used for: 

  • Ambulances
  • Equipment
  • Laboratories
  • Portable X-rays or mammography
  • State Vaccine Programs (SVP)

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Jul 11, 2019
  • Modified: Jul 11, 2019
  • View »