U.S. Territories Provider Forms

<h2>U.S. TERRITORIES PROVIDER FORMS</h2> <table border="0" style="width: 492pt; margin-left: -6pt;" width="656"> <tbody> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="656" style="width: 492.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{fontweight=500:For Puerto Rico PCM ONLY} To authorize specialty services to International SOS.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="656" style="width: 492.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/prcivilianpcmpatient-referral-form-nov-2023:Puerto Rico Primary Care Manager Patient Referral Authorization}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="656" style="width: 492.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{fontweight=500:Provider Application Forms (U.S. Territories ONLY)} These Provider Application Forms are for International SOS Network or TRICARE Participating Providers in the U.S. Territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands) to assist in the delivery of health care services for TRICARE Overseas Program (TOP) beneficiaries.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/allied-health-app-18761f:Allied Health Provider Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/ambulance-file-app-13660f:Ambulance Provider File Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/ambulatory-surgical-center-app-21435f:Ambulatory Surgical Center Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/birthing-center-app-19874f:Birthing Center Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/certified-nurse-midwife-app-1401f:Certified Nurse-Midwife Provider File Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/clinic-or-group-practice-app-12417f:Clinic or Group Practice Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/corporate-services-20975f:Corporate Service Providers Class Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/dietician-nutritionist-app:Dietician-Nutritionist Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/durable-medical-equipment-supply-app-18762f:Durable Medical Equipment and Supply Provider File Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/home-health-agency-app-18232f:Home Health Agency Provider File Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/Reimbursement-of-CAP-DME-Costs:Reimbursement of Capital and Direct Medical Education Costs Form}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/independant-lab-app-18232f:Independent Laboratory Provider File Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/hospice-program-app-21148f:Hospice Program Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/MHS-Practitioner-Application-Form-March2026:MHS Practitioner Application Form}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/Institutional-Provider-App-18424F:Institutional Provider File Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/pharmacy-app-21165f:Pharmacy Provider File Application}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/physician-provider-application-form-11343F:Physician Provider File Application}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/physiological-laboratories-app-18232f:Physiological Laboratory Applications - All Other Overseas Countries}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" width="332" style="width: 249.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/puerto-rico-psychologist-app:Physiological Laboratory Application - Puerto Rico Only}</td> <td colspan="1" rowspan="1" width="324" style="width: 243.0pt; padding: 6.0pt 6.0pt 6.0pt 6.0pt; height: 15.0pt;">{downloaddocs=/tricareoverseas/providers/tco-media/documents/skilled-nursing-app-21144f:Skilled Nursing Facility Application}</td> </tr> </tbody> </table> <h2> </h2>

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