Provider Registration


Register for the Veterans Choice Program to Provide Care to Veterans

The Veterans Choice Program (VCP) is the most recent addition to the PC3 program. This program allows eligible Veterans to seek care from community providers if they face wait times longer than 30 days for care from a VA provider, or the closest VA medical facility is greater than 40 miles from their home. The VCP provides eligible Veterans with a Veterans Choice Card to enhance access to primary care, inpatient and outpatient specialty services, and behavioral health care. To confirm your interest in serving our nation’s Veterans under the VCP, please review the general “Terms and Conditions” and complete the registration form which allows TriWest to list you in a directory of providers who have expressed a willingness to treat Veterans using the Veterans Choice Program. If you have any questions about the VCP registration, feel free to contact our Choice line at 1-866-606-8198 and select option 2.

Date Entered:
6/28/2017 12:04:40 AM
Program:
CHOICE
* = Required
Name: (Must fill in the Provider's First and Last Name and/or the Facility/Group Name)
Provider First Name: *
Provider Last Name: *
Degree:
Facility/Group Name: *
Number of Providers in Group: *
States Served: *
hold down 'CTRL' key to select multiple states
Specialty: *
Federal Healthcare Clinic:
(select if you are an FQHC, CHC, or RHC)
Tax ID: *
NPI: * (Must enter an Individual NPI, Organizational NPI or both)
Individual
Organizational
Address
Street Address 1 *
Street Address 2
Optional
City *
State *
Zip Code *
 
Provider Point of Contact
Name *
Email *
Phone *
Fax
Optional
State License Number
DEA License Number
Remit Address
Medicare Certification Number
Comment
If you are a large health care organization with more than 10 providers, please fill out the provider registry form and send it with a copy of your W-9 via fax to 1-866-269-5891 or email to choiceprovider@triwest.com.
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