Tricare Provider Information Below you will need to upload your: Certificate/Letter issued by the Behavior Analyst Certification Board (BACB) CPR training certificate Criminal History Background Check (You will need to obtain this document your employer.) Your Name* First Middle Last Your Personal Email* Your Personal Phone*Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Gender* Male Female Your Date of Birth* State of Birth*ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificYour Social Security Number* Name of Clinic You Work For* What is the day you started working/will start at this clinic?*(First date treating patients) MM slash DD slash YYYY Do you have an Individual NPI Number?*If not, we will get you one. Yes No If yes, what is it? Are you employed by the U.S. government?* Yes No Provider Type* Registered Behavior Technician (RBT) Board Certified Assistant Behavior Analyst (BCaBA) Name of School*Please list the name of the school of the highest level of education you have COMPLETED. So for example if you are in college but not yet graduated, list the high school you earned a diploma at. School Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Degree Earned* High School Bachelor of Arts Bachelor of Science Master of Arts Master of Science Start Date*What date did you start with this school? MM slash DD slash YYYY End Date*What date did you finish with this school? MM slash DD slash YYYY Bachelor Degree informationUniversity Name* University Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Degree* Start Date*What date did you start with this school? MM slash DD slash YYYY End Date*What date did you finish with this school? MM slash DD slash YYYY Your Behavioral Analyst Certification Board (BACB) InformationCertificate Number* Effective Date* MM slash DD slash YYYY Expiration Date* MM slash DD slash YYYY For BCaBAs who supervise BTs, an eight-hour, competency-based training covering the BACBs Supervising Training Curriculum Outline and three hours of continuing education related to supervision needs to be completed during each BACB certification cycle. Have you completed this?*This is a requirement to become Tricare certified. Yes No Date Completed MM slash DD slash YYYY Upload your 1.) Certificate/Letter issued by the Behavior Analyst Certification Board (BACB) and 2.) your CPR training certificate and 3.) Criminal History Background Check (from your employer) Drop files here or Select files Max. file size: 256 MB. Comments? Δ
