Get Tricare Non Network Physiciandentist Individual Application Form
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How to fill out the Tricare Non Network Physician/Dentist Individual Application Form online
This guide provides clear instructions on how to complete the Tricare Non Network Physician/Dentist Individual Application Form online. By following these steps, users can efficiently navigate through the form to ensure all necessary information is accurately provided.
Follow the steps to complete your application form.
- Click ‘Get Form’ button to access the application form and open it in the online editor.
- Begin filling out the personal information section. Input your first name, middle initial, and last name in the designated fields along with your gender, title, Social Security number, and National Provider Identifier (NPI) number.
- Provide your physical address in the specified fields, ensuring that all details are complete. If you have a different billing address, fill out that information as well.
- Enter your contact numbers, including two telephone numbers and a fax number if applicable. Add your email address to facilitate communication.
- Attach a list of any additional office locations you may maintain.
- Indicate whether you maintain a solo practice by selecting 'Yes' or 'No.' If applicable, provide the Tax ID number associated with your solo practice and the date you began using it.
- If you work with an established group practice or institution, confirm this by selecting 'Yes' or 'No.' If 'Yes,' provide the name of the practice, the practice's Tax ID number, and the date you began practicing with this group.
- Indicate whether you sign your own claim forms. If 'No,' make sure to check that signature authorization forms are attached and notarized.
- Complete the specialty section by entering your area of expertise, and provide your license number, original license date, and current expiration date. Attach a copy of your current state license.
- If applicable, answer questions about your employment status, such as whether you are employed by the U.S. government or currently a resident. Provide the name of the facility where you are completing your residency.
- Proceed to the notarized signature authorization section. Complete the required signatures and ensure they are notarized, as this might be necessary for the processing of your application.
- Fill out the Electronic Funds Transfer section if applicable, including your Tax Identification number, bank name, and account details. Authorize PGBA, LLC to process entries as necessary.
- Once all sections are completed, review your application for accuracy. Save your changes, download a copy for your records, and either print or prepare to share the form as required.
Begin your application process online today.
You can see any provider with TRICARE, but your costs will depend on whether they are in-network or out-of-network. Using an in-network provider usually results in lower out-of-pocket expenses. If you choose to see a non-network provider, you may need to complete the TRICARE Non Network Physician Dentist Individual Application Form to facilitate care. This ensures that you receive the necessary coverage while accessing a wider range of healthcare options.
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