Individual Applications

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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