Non-Network Provider Applications
Institution-Level Applications
- Institutional Provider Application
- Freestanding Psychiatric and Substance Use Disorder (SUD) Partial Hospitalization Program (PHP) Provider Application
- Inpatient/Residential Substance Use Disorder Rehabilitation Facility (SUDRF) Provider Application
- Institutional Intensive Outpatient Program (IOP) Provider Application
- Institutional Opioid Treatment Program (OTP) Provider Application
- Institutional Residential Treatment Center (RTC) Provider Application
Individual Provider Applications
- Autism Care Demonstration (ACD) Board Certified Behavior Analyst (BCBA/BCBA-D) and Licensed Behavior Analyst (LBA) Provider Application
- Austism Care Demonstration Corporate Service Provider (ACSP) Provider Application
- Ambulance Application
- Anesthesiologist Assistant (AA) Provider Application
- Birthing Center Application
- Christian Science Practitioner or Christian Science Nurse Provider Application
- Clinical Psychologist Provider Application
- Clinical Social Worker Provider Application
- Donor Milk Bank Supplier Application
- Equipment Supplier Application
- Home Health Agency Provider Application
- Hospice Provider Application
- Laboratory Application
- Lactation Consultant (LC) Certified Lactation Counselor (CLC) Certified Labor Doula(CLD)
- Certified Marriage and Family Therapist Provider Application
- Mental Health Counselor (SMHC/TCMHC) Provider Application
- Pastoral Counselor Provider Application
- Physical Therapist/Speech Therapist/Occupational Therapist/Audiologist Provider Application
- Physician/Dentist Provider Application
- Portable X-Ray or Mammography Supplier Application
- Provider's Notarized Facsimile or Stamp Signature Authorization
- Skilled Nursing Facility Provider Application
- State Vaccine Program Supplier Application
Other Forms
- Instructions for Completing the TRICARE West NPI Form
- Practitioner Affiliation/Disaffiliation Request Form
- Provider Autism Care Demonstration Basic life Support (BLS)/CPR Requirement Form
- Provider Information Update Request Form
- Provider Specialty Information Update Request Form
- UB-04 "Signature on File" for TRICARE Claims Form