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TRICARE Policy Manual 6010.60-M, April 1, 2015
Providers
Chapter 11
Addendum C
Application Form For Corporate Services Providers
Revision:  C-13, November 15, 2017
Figure 11.C-1  TRICARE Corporate Services Application
Name: _______________________________________________________________________________
Corporate/foundation name if different: ___________________________________________________
ADDRESS:
Physical location (street, city, state, zip)
Mailing Address (if different)
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Area code and TELEPHONE NUMBER:
Area code and FACSIMILE NUMBER:
_______________________________________
_______________________________________
TAX ID NUMBER:
National Provider Identifier (NPI) #
_______________________________________
_______________________________________
Are you a MEDICARE provider:
( ) Yes
( ) No
If yes: Medicare certification number:
_______________________________________
Medicare Category:
_______________________________________
Medicare acceptance date:
_______________________________________
Are you JC accredited?
( ) Yes
( ) No
If yes: JC classification:
_______________________________________
JC classification dates:
FROM: _____________
TO: ________________
State License classification:
_______________________________________
State License dates:
FROM: _____________
TO: ________________
Are you certified by a national board?
( ) Yes
( ) No
If yes: Name of National board:
_______________________________________
Effective date of certification:
_______________________________________
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