Provider Information Form

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

We require 30 days to process new PIFs. Please allow for this time frame before contacting us regarding your application status. The full credentialing process may take anywhere from 60 days to 180 days from the time we receive a complete application.

Please use the fax cover sheet included in this PDF 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 105422
Atlanta, GA 30348-5422

Fax:
1-888-428-8710

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 Provider Demographic Updates form or the Network Provider Directory.

Behavioral health providers should not fill out the PIF. Visit the MHN website and click on Join Our Network for questions about joining the behavioral health TRICARE network and the MHN credentialing process.

  • Created: Apr 15, 2014
  • Modified: Apr 15, 2014
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