Revised: 4/15/2020 TRICARE is a registered trademark of the
Department of Defense, Defense Health Agency. All rights
reserved.
TRICARE NON-NETWORK BCBA-D, BCBA and BCaBA/QASP
Comprehensive Autism Care Demonstration Attestation Form
Please submit the completed package to:
Fax: 844-730-1373
or
Mail to: TRICARE West
Provider Data Management PO Box 202106
Florence, SC 29502-2106
Health Net Federal Services offers payments and remittances by
National Provider Identifier (NPI) number. The NPI billed on the
claim will determine where payment and remittance will be sent. It
is critical the information provided matches how your office will
file claims. Inconsistent data will negatively impact claims
payment.
If your business requires multiple mailing/payment addresses,
please provide an NPI for each. If you have more than one NPI, you
must complete a separate application for each NPI number.
Revised: 4/15/2020 TRICARE is a registered trademark of the
Department of Defense, Defense Health Agency. All rights
reserved.
TRICARE NON-NETWORK BCBA-D, BCBA and BCaBA/QASP
Comprehensive Autism Care Demonstration Attestation Form
As a condition of assigning a provider to a TRICARE beneficiary,
I certify the provider(s) listed on the attached roster meet the
following requirements applicable to their provider category.
Please attach a provider roster if this attestation is for more
than one BCBA-D, BCBA and BCaBA/QASP and information for all is the
same. If the information not the same, please complete a separate
attestation form for each BCBA-D, BCBA and BCaBA/QASP
Provider First Name_______________________ Provider Last
Name____________________________
Tax ID: _________________________________ NPI:
_______________________________________
Date this provider began practicing with this group:
___________________________________________
PROVIDER CATEGORIES:
Board Certified Behavior Analyst-Doctoral (BCBA-D) BCBA-D #:
________________________ Board Certified Behavior Analyst (BCBA)
BCBA #: __________________________ Board Certified Assistant
Behavior Analyst (BCaBA) BCaBA #: _________________________
Qualified Autism Services Practitioner (QASP) QASP #:
_____________________________
REQUIREMENTS:
Has current (within 45 days of hire) Federal, State, and County
Criminal and Sex Offender reportsfor all locations the provider has
resided or worked during the previous 10 years
Has NEVER been convicted of a felony
Bachelor’s Degree (BCaBA/QASP), Master’s or Doctoral Degree
(BCBA/BCBA-D)
Date Graduated: ____________________ Degree Earned/program:
______________________
Name of University:
________________________________________________________
State License or state certification:
License Number: ___________________________
Original License Date: _______________________ Expiration Date:
_____________________ (mm/dd/yyyy) (mm/dd/yyyy)
Has completed Basic life support training or CPR-equivalent
certification via a live classroom thatincludes practice on a dummy
on or after January 1, 2016.Date Completed: ________________
(mm/dd/yyyy)
Revised: 4/15/2020 TRICARE is a registered trademark of the
Department of Defense, Defense Health Agency. All rights
reserved.
SIGNATURES:
I attest this provider meets all of the above certification
requirements as specified in TRICARE Operations Manual (TOM)
Chapter 18, Section 4. I attest the information provided is
complete, accurate, and true to the best of my knowledge.
_________________________________________
____________________________ ASCP Representative Signature Date
Please mail or fax the completed package to PGBA, LLC:
TRICARE West Provider Data Management
PO Box 202106 Florence, SC 29502-2106
Fax: 844-730-1373
Please submit the completed package to:Fax: 844-730-1373
Date: Provider First Name: Provider Last Name: Tax ID: NPI:
Board Certified Behavior AnalystDoctoral BCBAD: OffBoard Certified
Behavior Analyst BCBA: OffBoard Certified Assistant Behavior
Analyst BCaBA: OffQualified Autism Services Practitioner QASP:
OffBCBAD: BCBA: BCaBA: QASP: Has current within 45 days of hire
Federal State and County Criminal and Sex Offender: OffHas NEVER
been convicted of a felony: OffMasters or Doctoral Degree:
OffMasters Date Graduated: Degree Earned: Name of University: State
License or state certification: OffState License Number: Original
License Date: Expiration Date: Has completed Basic life support
training or CPRequivalent certification via a live classroom that:
OffBLS Date Completed: Provider Group Start Date: