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Network Provider Information Form

In addition to the CAQH credentialing application, TRICARE network provider applicants (does not apply to non-network providers) must also submit a supplemental Provider Information Form or PIF. This supplemental application requests information unique to TRICARE that is not addressed within the CAQH application. You may mail or fax your completed PIF.

  • Provider groups: Provider groups with 20 or more individual providers can complete the TRICARE Provider Group Roster rather than a PIF for each provider.  
  • Mental health providers: Mental health providers should not fill out the PIF or group provider roster. Visit the MHN website and click on Join Our Network for questions about joining the behavioral health TRICARE network and the MHN credentialing process.

We require 30 days to process new PIFs. Please allow for this time frame before contacting us regarding your application status. Keep in mind, the full credentialing process takes, on average, 60–90 days from the date we receive a completed application. You can check status using our Check Credentialing Status tool.

If faxing, use the fax cover sheet included in the form as the first page of your fax. Applications that do not have this cover sheet as the first page of the fax will not be processed.

Mailing Address:
Health Net Federal Services, LLC/TRICARE
Attn: Provider Network Management
PO Box 9710
Virginia Beach, VA 23450-9710

Fax:
1-844-224-0381

Note: Do not use this form to update demographic information. This form is for credentialing purposes only. You may update your demographic information using the Network Provider Directory.

  • Created: Aug 23, 2018
  • Modified: Aug 23, 2018
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