Tricare Rtc Application PDF Details

The Tricare Retiree Dental Plan is a dental insurance plan available to retirees of the military and their families. This plan offers comprehensive coverage for preventive, diagnostic, and restorative services. In order to be eligible for this plan, you must first complete the Tricare RTC application form. The deadline to submit your application is usually around 60 days before your retirement date. In this blog post, we'll provide an overview of the Tricare Retiree Dental Plan and walk you through the process of completing the Tricare RTC application form.

In the listing, there's some good information regarding the tricare rtc application. You may learn its length, the typical time needed to complete the form, the blanks you'll need to fill in, and so on.

Form NameTricare Rtc Application
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesNPI, provider application for rtc tricare east, RTC, GDFT

Form Preview Example

Residential Treatment Center (RTC)


Patient’s Name:




Sponsor SSN:






Date of Application:


Patient Address:












Name of Parent/Legal Guardian:










Other Insurance: Yes*


*If yes, please specify:







Patient’s current placement:






Other family


Foster Setting

Juvenile Detention


This application must be completed, legible, and signed by the current treating Physician or Clinical Psychologist (PsyD or PhD). No other licensed clinicians can refer) who is recommending treatment in a RTC to avoid any delays. Information must be current and based on recent contact with the patient and family. Please fax this completed form with attachments to

FAX: (866) 811-4422

Note: Parent/guardian(s) may want to duplicate all of these materials since much of the same information will be required by the facility for which the applicant is being considered.

Services must be provided by a KePRO- Certified RTC for Children and Adolescents. A list of RTCs is available on the KePRO website:


To assist in determining medical necessity for residential treatment placement it is strongly recommended that the following clinical documentation be provided as available/applicable:

Current Psychiatric Evaluation by a psychiatrist (within 30 days of the request)

Detailed psychosocial history

If hospitalized, include the family therapy, individual therapy and doctor’s progress notes for the current stay and indication of the outpatient provider support of RTC.

Clinical from Previous Inpatient Psychiatric admissions

If outpatient, include a letter from each outpatient provider summarizing the intensity of treatment over the past six (6) months and why treatment is failing or a copy of the treatment records for the past eight (8) visits.

***Failure to complete all fields and include the supporting legible documentation could result in an adverse decision. ***

DSM 5 Diagnosis:

Is there cognitive/intellectual impairment? Yes* No * If yes, attach copies of psychological tests & describe:

Page 1 of 4

UM: 9/09: REVIEWED: 6/10, 5/11, 6/12, 6/13, 10/13, 11/13

Residential Treatment Center (RTC)


Are there any significant physical or medical problems? Yes* No If yes, please describe:

Describe in detail patient’s current condition, including mental status and behavior symptoms, for which Residential Treatment might be necessary.

Reasons why the patient cannot be treated at a lower level of care?

What attempts have been made to treat the patient with the maximum intensity of services available at a less intensive level of care, especially within the past 6 months:











Individual Therapy





Family Therapy





Partial Hospital





Psychiatric Medication
























Hospitalization(s) (last 3























Community Services





Child Protective Services





Arrests/Legal Charges





School Services





Military Agencies





Case Management





Page 2 of 4

UM: 9/09: REVIEWED: 6/10, 5/11, 6/12, 6/13, 10/13, 11/13

Residential Treatment Center (RTC)


Current Psychiatric Medications


Past Psychiatric Medication Trials

Start/End Date

Results/Reason for Discontinuation

Substance Type


Duration Age Started

Last Use Treatment


Describe patient’s current family structure (living situation, parental roles, family strengths, areas needing improvement):

List goals necessary and attainable for the patient/family within a Residential Treatment setting. Treatment duration may be several months:




Page 3 of 4

UM: 9/09: REVIEWED: 6/10, 5/11, 6/12, 6/13, 10/13, 11/13

Residential Treatment Center (RTC)


If family involvement is therapeutically contraindicated, please explain.

Are any barriers anticipated with reunification back into the family home after discharge from RTC?

Family Therapy Requirements:

If the custodial parent resides within 250 miles of the RTC, the custodial parent/family is encouraged to participate in weekly on-site family therapy.

If the custodial parent resides more than 250 miles from the RTC, the custodial parent/family is encouraged to participate in monthly on-site family therapy and weekly geographic distant family

therapy (GDFT).

This requirement has been discussed with the custodial parent; they understand and agree to participate


Name of local therapist proposed to participate in GDFT, if applicable:

Requested Facility:

Estimated Length of Stay:





Licensure type: MD DO PsyD


Provider NPI #




(No other licensure type accepted)








Provider Address:
















Provider Telephone:


Provider Fax:






Provider Point of Contact:








Physician/Psychologist Certification:




I certify that I am the person rendering this patient’s face to face clinical services and the above statements are true and I have obtained appropriate signed release for all information provided to TRICARE South Division Behavioral Health.

Provider Printed Name:

Provider Signature:




Complete all fields in this application. Indicate “N/A” for sections that are not applicable.

In order for ValueOptions® to communicate healthcare related information to anyone other than the

beneficiary/patient Authorization for Release of Information (ROI) forms may be required even for minor children.

Page 4 of 4

UM: 9/09: REVIEWED: 6/10, 5/11, 6/12, 6/13, 10/13, 11/13

How to Edit Tricare Rtc Application Online for Free

We were developing the PDF editor having the idea of making it as fast to work with as possible. For this reason the actual procedure of filling out the PhD will likely to be simple carry out all of these actions:

Step 1: Select the button "Get Form Here" on the following website and press it.

Step 2: The document editing page is right now open. It's possible to add text or edit existing content.

For each section, prepare the information asked by the software.

tricare empty fields to consider

You should prepare the DSM Diagnosis, Is there cognitiveintellectual, UM Reviewed, and Page of box with the necessary particulars.

Finishing tricare step 2

The program will require you to give particular relevant data to automatically complete the segment Residential Treatment Center RTC, Are there any significant physical, Describe in detail patients, and Reasons why the patient cannot be.

Finishing tricare part 3

The What attempts have been made to, Providers, Frequency, Comments, StartEnd Dates, Individual Therapy Family Therapy, Psychiatric Hospitalizations last, and Community Services Child section is where all sides can place their rights and obligations.

Filling out tricare part 4

Review the sections Current Psychiatric Medications, DoseFrequency, Past Psychiatric Medication Trials, StartEnd Date, ResultsReason for Discontinuation, Substance Type, AmountFrequency Duration Age, Last Use Treatment, OutcomeResults, and Describe patients current family and next complete them.

Filling out tricare step 5

Step 3: When you click the Done button, your completed file is simply transferable to every of your gadgets. Or, you can deliver it through mail.

Step 4: Generate a duplicate of each file. It will certainly save you some time and assist you to prevent challenges in the future. By the way, your details isn't going to be distributed or checked by us.

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