<h2><strong>U.S. TERRITORIES PROVIDER FORMS</strong></h2>
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<td colspan="2" rowspan="1" width="656" style="padding: 6pt; width: 492pt; height: 15pt;"><p style="margin: 6pt 0in;">{fontweight=500:For Puerto Rico PCM ONLY}<br> To authorize specialty services to International SOS.</p></td>
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<td colspan="2" rowspan="1" width="656" style="padding: 6pt; width: 492pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/prcivilianpcmpatient-referral-form-nov-2023:Puerto Rico Primary Care Manager Patient Referral Authorization}</p></td>
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<td colspan="2" rowspan="1" width="656" style="padding: 6pt; width: 492pt; height: 15pt;"><p style="margin: 6pt 0in;">{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.</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/allied-health-app-18761f:Allied Health Provider Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/ambulance-file-app-13660f:Ambulance Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/ambulatory-surgical-center-app-21435f:Ambulatory Surgical Center Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/birthing-center-app-19874f:Birthing Center Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/certified-nurse-midwife-app-1401f:Certified Nurse-Midwife Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/clinic-or-group-practice-app-12417f:Clinic or Group Practice Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/clinical-psychologist-app-18220f:Clinical Psychologist Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/clinical-social-worker-app-17289f:Clinical Social Worker Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/corporate-services-20975f:Corporate Service Providers Class Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/dietician-nutritionist-app:Dietician-Nutritionist Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/durable-medical-equipment-supply-app-18762f:Durable Medical Equipment and Supply Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/home-health-agency-app-18232f:Home Health Agency Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/Reimbursement-of-CAP-DME-Costs:Reimbursement of Capital and Direct Medical Education Costs Form}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/independant-lab-app-18232f:Independent Laboratory Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/hospice-program-app-21148f:Hospice Program Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/mental-health-counselors-app-17287f:Mental Health Counselors Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/Institutional-Provider-App-18424F:Institutional Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/pharmacy-app-21165f:Pharmacy Provider File Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/Pastor-Counselor-App-17288F-CB:Pastoral Counselor Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/physiological-laboratories-app-18232f:Physiological Laboratory Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/physician-provider-application-form-11343F:Physician Provider File Application}</p></td>
<td colspan="1" rowspan="1" width="318" style="padding: 6pt; width: 238.5pt; height: 15pt;"><p style="margin: 6pt 0in 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/skilled-nursing-app-21144f:Skilled Nursing Facility Application}</p></td>
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<td colspan="1" rowspan="1" width="338" style="padding: 6pt; width: 253.5pt; height: 15pt;"><p style="margin: 6pt 0in;">{downloaddocs=/providers/tco-media/documents/puerto-rico-psychologist-app:Physiological Laboratory Application}</p></td>
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<h2><br></h2>