<h2><strong>U.S. TERRITORIES PROVIDER FORMS</strong></h2> <table border="0" style="width: 310pt;" width="413"> <colgroup> <col width="207" style="width: 155pt;"> </colgroup> <colgroup> <col width="206" style="width: 155pt;"> </colgroup> <tbody> <tr height="20" style="height: 15pt;"> <td colspan="2" rowspan="1" width="413" height="20" style="height: 15pt; width: 310pt;">{fontweight=500:For Puerto Rico PCM ONLY}<br> To authorize specialty services to International SOS.</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="2" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/prcivilianpcmpatient-referral-form-nov-2023:Puerto Rico Primary Care Manager Patient Referral Authorization}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="2" rowspan="1" width="413" height="20" style="height: 15pt; width: 310pt;">{fontweight=500:Provider Application Forms (U.S. Territories ONLY)}<br> 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 height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/allied-health-app-18761f:Allied Health Provider Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/ambulance-file-app-13660f:Ambulance Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/ambulatory-surgical-center-app-21435f:Ambulatory Surgical Center Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/birthing-center-app-19874f:Birthing Center Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/certified-nurse-midwife-app-1401f:Certified Nurse-Midwife Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/clinic-or-group-practice-app-12417f:Clinic or Group Practice Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/clinical-psychologist-app-18220f:Clinical Psychologist Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/clinical-social-worker-app-17289f:Clinical Social Worker Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/corporate-services-20975f:Corporate Service Providers Class Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/dietician-nutritionist-app:Dietician-Nutritionist Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/durable-medical-equipment-supply-app-18762f:Durable Medical Equipment and Supply Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/home-health-agency-app-18232f:Home Health Agency Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/hospice-program-app-21148f:Hospice Program Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/independant-lab-app-18232f:Independent Laboratory Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/institutional-provider-app-18424f:Institutional Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/mental-health-counselors-app-17287f:Mental Health Counselors Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/institutional-provider-app-18424f:Pastoral Counselor Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/pharmacy-app-21165f:Pharmacy Provider File Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/physician-provider-application-form:Physician Provider File Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/physiological-laboratories-app-18232f:Physiological Laboratory Application}</td> </tr> <tr height="20" style="height: 15pt;"> <td colspan="1" rowspan="1" height="20" style="height: 15pt;">{downloaddocs=/providers/tco-media/documents/puerto-rico-psychologist-app:Physiological Laboratory Application}</td> <td colspan="1" rowspan="1" style="">{downloaddocs=/providers/tco-media/documents/skilled-nursing-app-21144f:Skilled Nursing Facility Application}</td> </tr> </tbody> </table> <p><br></p>