Provider Information Form Fax Cover Sheet - TRICARE West 2025

1. Click ‘Get Form’ to open the Provider Information Form Fax Cover Sheet in the editor.
2. Begin by filling out the 'Fax to' section with 'Health Net Federal Services, LLC' and the fax number '1-844-224-0381'.
3. Complete the identifying information fields, including your last name, first name, date of birth, and other required identifiers such as Tax Identification Number and National Provider Identifier (NPI). Ensure all entries match your CAQH application.
4. In the practice information section, provide details about your practice name, physical address, phone numbers, and billing information. Make sure this information is accurate for processing.
5. Review any additional sections relevant to your specialty or services provided. If applicable, complete the mental health provider requirements or telemedicine attestation.
6. Once all fields are filled out correctly, save your document and use our platform's features to sign if necessary before sending it via fax.

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