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Tricare east provider application form 2026

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The document outlines the application process and requirements for hospice providers seeking to participate in the TRICARE program. It includes details on provider qualifications, billing procedures, payment agreements, and compliance with federal regulations. The agreement emphasizes the responsibilities of hospice programs in delivering care to TRICARE beneficiaries, including certification requirements, coverage conditions, and audit provisions. Additionally, it addresses the terms for electronic funds transfer and enrollment for electronic remittance advice.

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Click ‘Get Form’ to open the TRICARE East Provider Application Form in the editor.
Begin by filling in the 'Facility Name' and 'Federal Tax No.' fields. Ensure that your NPI number is also entered accurately.
Provide your office and billing telephone numbers, including extensions if applicable. This information is crucial for communication.
Complete the 'Office Location' and 'Mailing Address' sections. If they differ, make sure to specify both clearly.
Indicate whether your facility is Medicare certified by selecting 'YES' or 'NO'. If yes, fill in the certification details as required.
Attach copies of necessary certifications such as Medicare, JCAHO, and state licensing as instructed in the form.
Review all entries for accuracy before submitting. Use our platform's features to save your progress and make edits easily.

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