Fillable TRICARE NON-NETWORK PHYSICAL THERAPIST/SPEECH THERAPIST/OCCUPATIONAL THERAPIST/AUDIOLOGIST PROVIDER APPLICATION

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TRICARE NON-NETWORK PHYSICAL THERAPIST/SPEECH THERAPIST/OCCUPATIONAL THERAPIST/AUDIOLOGIST PROVIDER APPLICATION

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Revised: 12/6/2018
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
TRICARE NON-NETWORK
PHYSICAL THERAPIST/SPEECH THERAPIST/OCCUPATIONAL
THERAPIST/AUDIOLOGIST
PROVIDER APPLICATION
We expect providers to submit claims electronically. If it is necessary to submit a paper claim, the
only acceptable forms are the approved red and white NUCC 1500 (02-12) form and the NUBC
UB-04 (CMS -1450) forms. These forms must include the instructions on the back page
Speech, Occupational and Audiology Therapy Assistants are not eligible for reimbursement under TRICARE.
Please submit the completed application package to:
Fax: 844-730-1373
or
Mail to:
TRICARE West
Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Health Net Federal Services offers payments and remittances by National Provider Identifier (NPI) number.
The NPI billed on the claim will determine where payment and remittance will be sent. It is critical the
information provided matches how your office will file claims. Inconsistent data will negatively impact claims
payment.
If your business requires multiple mailing/payment addresses, please provide an NPI for each. If you have
more than one NPI, you must complete a separate application for each NPI number.
Revised: 12/6/2018
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
TRICARE Non-Network Provider Application
First Name: __________________________ MI: ____ Last Name: _____________________________
Gen: _______ Title: ____________________________________________________
Social Security #: _____________________________ NPI#: ________________________________
Are you employed by the US Government? ____ Yes ____ No
Do you sign your own claim forms? ____ Yes ____ No
If No, Signature Authorization forms are attached. Please complete these forms and have them notarized for
each practitioner. Without signature authorization forms on file, each claim will require a physical signature
from the rendering provider and claims without signature will be returned without processing the claim for
payment.
Do you maintain a solo practice? ____ Yes ____ No
Solo Practice Information
Solo Practice Tax ID: ________________________ NPI#: ________________________________
Date you began using this Tax ID #: (mm/dd/yyyy) _______________
Solo Physical Address (Street Address): Solo Billing Address for this NPI:
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
Telephone #: __________________________ Billing Telephone #: _____________________
Fax #: ________________________________ Email: ________________________________
Do
you work with an established group practice or institution? ____ Yes ____ No
Group Practice Information
If you practice at multiple locations, please provide the information below for each location.
Group Practice Name: ____________________________________________________________
Group Practice Tax ID #: _________________________ NPI#: ____________________________
Effective date of the group’s Tax ID number or EIN (Date legal entity established): _____________
(mm/dd/yyyy)
Date you began practicing with this group number: ______________________
(mm/dd/yyyy)
Group Physical Address (Street Address): Group Billing Address for this NPI:
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
Telephone #: __________________________ Billing Telephone #: _____________________
Fax #: ________________________________ Email: ________________________________
Revised: 12/6/2018
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
To c
ertify you as a Physical Therapist/Speech Therapist/Occupational Therapist/Audiologist, please
provide the following information to confirm you meet TRICARE requirements. PGBA, LLC must have
complete provider documentation on file to determine provider eligibility. To confirm you meet requirements,
the information provided must be legible, specific and match the criteria listed. Failure to provide complete
and accurate information will negatively impact claims payment.
Licensure: (Select applicable license)
___ Physical Therapist
___ Speech Pathologist
___ Occupational Therapist
___ Audiologist
___ Hippotherapy Physical Therapist/Occupational (A copy of your certificate from the American
Hippotherapy Certification Board is required)
License Number: _______________________________
Or
iginal License Issue Date: _______________ Expiration Date: _______________
or
If you practice in a state that does not offer licensure as a Speech Pathologist or Audiologist, please provide
the following:
Certification: has a certificate of membership in the American Speech, Language and Hearing Association
or is certified by the American Board of Audiology
____ Y
es ____ No
Cer
tification Number: _____________________________________
Or
iginal Issue Date: _______________ Expiration Date: _______________
(mm/dd/yyyy) (mm/dd/yyyy)
By
signing below, I attest to meeting the above TRICARE requirements. I understand that federal laws 18
U.S.C. 287 and 1001 provide for criminal penalties for submitting knowingly or making any false, fictitious or
fraudulent statement or claim in any matter within the jurisdiction of any department or agency of the United
States.
Practitioner Signature: ___________________________________________ Date: _______________
Revised: 12/6/2018
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
PROVID
ER'S NOTARIZED FACSIMILE OR STAMP SIGNATURE AUTHORIZATION
State of ___________________________
County of __________________________
____________
_________________________ being first duly sworn, deposes and says: I hereby
authorize PGBA, LLC / Health Net Federal Services in the state of South Carolina to accept my
facsimile or stamp signature shown below.
(Facs
imile, stamp or computer generated signature as it will appear on the claim form.)
as my
true signature for all purposes under TRICARE in the same manner as if it were my actual
signature, including my agreeing to abide by the TRICARE payment system concept and the
remainder of the certification normally signed by the source of care as it appears on all TRICARE
claim forms.
____________
______________________________
Signature
Subscribed and sworn to before me this ____________ day of _______________ 20____.
____________
_______________________________________
Notary Public in and for
___________
_____ County, State of _____________________
(SEAL)
My Commis
sion expires ________________________________________
Revised: 12/6/2018
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
PROVID
ER'S NOTARIZED SIGNATURE AUTHORIZATION
State of _____
______________________
County of __________________________
Know al
l persons by these presents:
That I, ______________________________ have made, constituted and appointed and
by these presents do make constitute and appoint ______________________________ my true
and lawful attorney-in-fact for me and in my name place and stead to sign my name on claims, for
payment for services provided by me submitted to TRICARE. My signature by my said attorney-
in-fact includes my agreement to abide by the TRICARE payment system concept and the
remainder of the certification appearing on all TRICARE claim forms. I hereby ratify and confirm
all that my said attorney-in-fact shall lawfully do or cause to be done by virtue of the power
granted herein.
In wi
tness whereof I have hereunto set my hand this ________day of _______________ 20___.
__________________________________________
Signature
Subscri
bed and sworn to before me this ____________ day of _______________ 20____.
____________
_______________________________________
Notary Public in and for
________________ County, State of _____________________
(SEAL)
My Commis
sion expires _____________________________
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TRICARE NON-NETWORK PHYSICAL THERAPISTSPEECH THERAPISTOCCUPATIONAL THERAPISTAUDIOLOGIST PROVIDER APPLICATION

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Completed 1 October 2021

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