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TRICARE Policy Manual 6010.63-M, April 2021
Providers
Chapter 11
Addendum C
Application Form For Corporate Services Providers
Revision:  
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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