ContractParticipation Agreement Agreement • September 26th, 2014
SKILLED NURSING FACILITY (SNF) PARTICIPATION AGREEMENT Agreement Between TRICARE And (Provider) doing Business as (DBA) TRICARE Provider ID/Number Medicare Provider No. (To be completed by TRICARE Contractor) (To be completed by SNF) In order to receive payment under 32 Code of Federal Regulations (CFR) Part 199, DBA as the Provider of skilled nursing services, agrees to conform to the provisions of 32 CFR 199 and applicable provisions in TRICARE Manuals and applicable Medicare provisions in 42 CFR. This Agreement, upon submission by the Provider of skilled nursing services of acceptable assurance of compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by TRICARE, shall be binding on the Provider of skilled nursing services and TRICARE. The Provider of skilled nursing services certifies that: a. The Provider is licensed by the State having jurisdiction for the Provider’s area. b. The Provider is Medic
