DD Form 3030 Corporate Services Provider Application for TRICARE Prov

OMB No. 
OMB approval expires

CORPORATE SERVICES PROVIDER
APPLICATION FOR TRICARE PROVIDER STATUS

The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0720-0020). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

DIRECTIONS: To apply for certification as a TRICARE-authorized provider, read and complete all sections of this application and return it
with all attachments to the following address:

[Contractor's Name]
[Contractor's Provider Certification Unit Address]

FOR INQUIRIES, PLEASE CALL: [Contractor's provider-inquiry telephone number]
1. PROVIDER NAME

2. PROVIDER CERTIFICATION (All applications must be signed by the chief executive officer and dated.)
The above-named provider has applied to become a TRICARE-authorized provider. The signee certifies that the information in this application and
attachments is true and accurately represents and depicts the above-named provider.
a. SIGNATURE OF CHIEF EXECUTIVE OFFICER

b. DATE (YYYYMMDD)

3. INSTITUTION/CORPORATE SERVICES PROVIDER IDENTIFICATION INFORMATION
a. NAME

b. CORPORATE/FOUNDATION NAME (If different)

c. ADDRESS (Physical location) (Street, City, State and ZIP Code)

d. MAILING ADDRESS (If different)

N E E D S

D D

6 7

e. TELEPHONE NUMBER (Include Area Code)

f. FACSIMILE NUMBER (Include Area Code) g. TAX ID NUMBER

h. ARE YOU A MEDICARE PROVIDER?

YES

(1) MEDICARE CERTIFICATION NUMBER

(2) MEDICARE CATEGORY

i. ARE YOU A JCAHO ACCREDITED?

YES

(1) JCAHO CLASSIFICATION

NO (If Yes:)
(3) MEDICARE ACCEPTANCE DATE
(YYYYMMDD)

NO (If Yes:)

(2) ORIGINAL JCAHO CLASSIFICATION
DATE (YYYYMMDD)

j. STATE LICENSE CLASSIFICATION

(3) CURRENT JCAHO CLASSIFICATION DATES (YYYYMMDD)
FROM:

k. DATES OF STATE LICENSURE (YYYYMMDD)
FROM:

l. ARE YOU CERTIFIED BY A NATIONAL BOARD?
(1) NAME OF BOARD

TO:

YES

TO:

NO (If Yes:)
(2) EFFECTIVE DATE OF CERTIFICATION
(YYYYMMDD)

IMPORTANT: Please attach copies of applicable Medicare, JCAHO, state, and national board certificates/licenses.

DD FORM X644, 20160112 DRAFT

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