Non-Network Providers
This non-network certification application should be used for Corporate Services Providers.
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: Aug 1, 2022
- Modified: Jul 11, 2019
- View »
This non-network certification application should be used for groups.
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: Aug 1, 2022
- Modified: Jul 11, 2019
- View »
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: Aug 1, 2022
- Modified: Dec 2, 2021
- View »
These non-network institutional certification applications should be used for:
- Birthing centers
- Home Health Agencies
- Hospice
- Institutional
- Institutional Freestanding Psychiatric and Substance Use Disorder (SUD) Partial Hospitalization Programs (PHP)
- Institutional Intensive Outpatient Programs (IOP)
- Institutional Opioid Treatment Programs (OTP)
- Institutional Residential Treatment Centers (RTC)
- Institutional Substance Use Disorder Rehabilitation Facilities
- Skilled Nursing Facilities
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: Aug 1, 2022
- Modified: Jul 11, 2019
- View »
This form is used to affiliate or disaffiliate a practitioner to a professional service location. If adding a new professional service location, please use the Provider Information Update Request Form.
Return completed form to:
TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Aug 1, 2022
- Modified: Dec 30, 2017
- View »
This form is used to update provider information in the TRICARE Non-Network Provider file. This can include updates to your:
- Tax Identification Number (TIN)
- Billing or physical address
- Name
- National Provider Identifier (NPI)
Return completed form to:
TRICARE West Provider Data Management
P.O. Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Aug 1, 2022
- Modified: Nov 14, 2019
- View »
Non-network providers should use this form to update specialty information in the TRICARE West Region non-network provider file.
Note: If your specialty is mental health, you must complete the appropriate mental health application.
Return completed form to:
TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Aug 1, 2022
- Modified: Jun 12, 2018
- View »
Return completed form to:
TRICARE West Provider Data Management
PO Box 202106
Florence, SC 29502-2106
Fax: 1-844-730-1373
- Created: Aug 1, 2022
- Modified: Dec 30, 2017
- View »
These non-network supplier certification applications should be used for:
- Ambulances
- Equipment
- Laboratories
- Portable X-rays or mammography
- State Vaccine Programs (SVP)
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: Aug 1, 2022
- Modified: Jul 11, 2019
- View »
