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Individual Provider Certification Applications

These non-network individual provider certification applications should be used for:

  • Anesthesiologist assistants
  • Certified nurse midwifes
  • Christian Science practitioners
  • Clinical psychologists
  • Clinical social workers
  • Lactation consultants, certified lactation counselors and certified labor doulas
  • Marriage and family therapists
  • Mental health counselors
  • Nurse anesthetists
  • Nutritionists
  • Pastoral counselors
  • Physical therapists, speech therapists, occupational therapists, and audiologists
  • Physical or occupational therapy assistants (network and non-network PTAs/OTAs) 
  • Physicians and dentists
  • Physician assistants
  • Psychiatric nurse specialists
  • Registered dietitians
  • RNs, LPNs, Nurse Practitioners

Applications should be sent via mail or fax to:

TRICARE West – Provider Data Management
PO Box 202106
Florence, SC 29502-2106

Fax: 1-844-730-1373

  • Created: Dec 2, 2021
  • Modified: Dec 2, 2021
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