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Non-Network Provider Specialty Information Update Request Form

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
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