Your local managed care contractor will assist you with other types of facilities, contracts and rates. Please review and print all documents for your facility type and send all correspondence to:

MAXIMUS/NQMC Attn: Beth Friedman 1600 E. Northern Ave. Suite 100 Phoenix, AZ 85020

Mental Health Frequently    Asked Questions

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Applications to become a TRICARE Certified Provider of Care:

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(RTC) Certification forms:	(PHP) Certification Forms:	(SUDRF) Certification Forms:
Cover letter for all new application requests
Application	Application	Application
Table of Contents for RTC Standards	Table of Contents for PHP Standards	Table of Contents for SUDRF Standards
Standards for RTC	Standards for PHP	Standards for SUDRF
Title 32 Part 199.6 Authorized Providers TMA Version	Title 32 Part 199.6 Authorized Providers TMA Version	Title 32 Part 199.6 Authorized Providers TMA Version
Table of Contents for Participation Agreement	Table of contents For Hospital Based PHP PA	Table of Contents for Participation Agreement
Sample Participation Agreement	Sample Participation Agreement for Hospital Based PHP	Sample Participation Agreement
TMA Form 771	Table of contents For Freestanding PHP PA
	Sample Participation Agreement for Freestanding PHP

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Additional Information:

• When to notify MAXIMUS of changes and incidents
• Self-Assessment Form
• TRICARE Reimbursement Manuals
• Ownership Application
• Qualified Mental Health Professionals
• SUDRF FAQ