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: