Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to obtain the form and open it for completion in your preferred online editor.
2. Input the facility name as it is officially registered. If applicable, fill in the corporate or foundation name in the designated area.
3. Provide your Federal Tax Identification Number and National Provider Identifier. Ensure that this information matches your official documents.
4. Enter your telephone and facsimile numbers accurately. This contact information is crucial for communication.
5. Complete the physical location section with your street address, city, state, and postal code.
6. Fill out the billing address for the NPI, which may be the same as the physical address or different.
7. Indicate the date your legal entity was established.
8. Answer the Medicare-related questions accurately. If applicable, provide your Medicare certification number and the category details.
9. Include your JCAHO accreditation status and details if you are accredited.
10. Confirm your state license classification along with the dates of licensure.
11. If certified by a national board, indicate the name of the board and the effective date.
12. Select the appropriate service category that applies to your organization by checking the relevant boxes in the options provided.
13. Review all the information filled in the application to ensure it is complete and accurate.
14. Sign the application in the designated area, ensuring it is dated and signed by the chief executive officer.
15. Submit the completed application package via fax or mail to the provided contact information or guidelines.

Start your application process online to become a TRICARE-authorized provider today.