TRICARE: Standard Survey of Civilian Providers

OMB NO.: 0720-0031
EXPIRATION DATE: 08/31/2025

Office of the Assistant Secretary of Defense (HA)
DHA Analytics and Evaluation Division
C/O DataStat, Inc.
3975 Research Park Drive
Ann Arbor, MI 48108

OFFICIAL GOVERNMENT BUSINESS
************AUTO**SCH 5-DIGIT 53562
[Unique
Provider ID Number]
DAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTD
FOR: [Insert Provider Name]

Street Address

City,
State, and Zip

De
ar [Insert Provider Name],

1#
MM/DD/YYYY

02/05/2025

DSW *001-00001*

Dear ,

There are three easy ways to complete this 5-minute survey:

https:www.health.mil/Patient-Surveys
Select Survey #3: TRICARE Select Survey for Civilian Providers
Password:

2 Return by Mail

Use the enclosed pre-paid envelope

3 Return by Fax

1-734-663-9084

If you are not the appropriate person to answer these questions, please pass this on to the person in your
office most familiar with billing and insurance. If you have questions about the survey, call 1-866-387-9018.
Thank you in advance for your cooperation.
Sincerely yours,

Melissa D. Gliner, Ph. D.
Analytics and Evaluation Division, Defense Health Agency
Office of the Assistant Secretary of Defense (Health Affairs)

SURVEY QUESTIONS ON REVERSE SIDE

The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate,
Information Management Division, [email protected] (0720-0031). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This Official DoD survey
may be confirmed at the TRICARE website https://health.mil/surveys, click on Current Active Surveys, and find "Survey of Civilian Provider Acceptance of TRICARE Select."

PRIVACY ADVISORY STATEMENT
Information is being collected for this Survey under the authority of the FY2015 National Defense Authorization Act (NDAA), Section 712 and will be used to help TRICARE health policy
makers gauge civilian provider awareness and acceptance of the TRICARE Select health care benefit option and provide aggregated input to improve the Military Health System. All
information will be de-identified prior to being reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if
you choose not to respond, although maximum participation is encouraged so the data will be complete and representative. Personally identifying information (PII) includes names,
addresses, phone numbers, email addresses, Social Security numbers, medical IDs, etc. and should not be included in survey responses.

DSW-BH

*001-00001*

1 Complete Online

DSW-00469-02

Congress has directed the Department of Defense to survey civilian mental and behavioral health care
providers to determine if military service members and their families have access to care outside of the military.
To assess this, we are gathering details surrounding health insurance and new patient acceptance. Even if you
are not accepting new patients, please reply to the first question in this survey so that we may report accurate
statistics to Congress.

OMB NO.: 0720-0031
EXPIRATION DATE: 08/31/2025

1.
1.

On average,
average,does
does

provide
treatment
On

provide
treatment
to
to patients
at least
20 hours
per week?
patients
at least
20 hours
per week?

7.
7.

 Yes ➔ Go to Question 2
 No, does not provide treatment, has retired, or

2.
2.

As
oftoday,
today,isis

a TRICARE
a TRICARE
Select
As of

Select
network
member?
network member?

 No
 Yes
 Don't Know

provides treatment to patients less than 20 hours
per week on average. ➔ Thank you, please
return the questionnaire
 Don't know, no longer here. ➔ Thank you, please
return the questionnaire
Whichofofthe
thefollowing
following
best
describes

Which
best
describes

's
's principal employer?

8.
8.

As
oftoday,
today,isis

accepting
accepting
As of

newnew
TRICARE
Select
patients?
TRICARE Select
patients?

 Yes ➔ Go to Question 10
 No ➔ Go to Question 9
 Don't Know ➔ Go to Question 10

principal employer?

9.
9.

 Government-sponsored facility or Government- run

Why
is

not
notaccepting
accepting
new
Why is

new
TRICARE
TRICARE
Select patients?
Select patients?

program

 Military or Veteran treatment facility
 School, university, or other academic institution
 Contractor providing services for employment,

MARK ALL THAT APPLY












Reimbursement too low
Customer service/paperwork problems
Problems with TRICARE in the past
Not aware of TRICARE Select
Inconvenience
Specialty or credential not covered
Prefers TRICARE Prime or TRICARE Plus
Too busy
Only takes private insurance
Problems getting into program/application in
progress
 Not accepting new patients
 Other
__________________________ (do not include PII)

insurance, or legal proceedings
Closed Panel HMO
Open Panel HMO
Prison or jail
Other _____________________ (do not include PII)
Is

a case
manager
and/or
Is
a case
manager
and/or
medical
medical student?
student?






3.
3.

MARK ALL THAT APPLY
 Yes, case manager ➔ Thank you, please return
the questionnaire
 Yes, medical student ➔ Thank you, please return
the questionnaire
 No, neither a case manager nor medical
student ➔ Go to Question 4
4.

10.
10.

Are
ofof
TRICARE
Select
(formerly
known
as
Are you
youaware
aware
TRICARE
Select
(formerly
known
as
TRICARE
or or
Extra)?
TRICAREStandard
Standard
Extra)?

 Yes ➔ Thank you, please return the questionnaire
 No ➔ Go to Question 11
 Don't Know ➔ Go to Question 12

 Yes
 No
5.
5.

As of
of today,
today,isis

accepting
accepting
As

newnew
Medicarepatients?
patients?
Medicare

11.
11.

As of
oftoday,
today,does
does

accept
of
As
Dr.

accept any
of the any
following
the following
of health insurance?
forms
of healthforms
insurance?

Whyisis

not
notaccepting
accepting
new
Why

new
Medicare
Medicare patients?
patients?
MARK ALL THAT APPLY

Yes

No

Medicare





Medicaid





TRICARE Select





Private insurance





Other:














Reimbursement too low
Customer service/paperwork problems
Problems with Medicare in the past
Inconvenience
Specialty or credential not covered
Too busy
Only takes private insurance
Problems getting into program/application in
progress
 Not accepting new patients
 Other
__________________________ (do not include PII)

➔ Go to Question 9

(do not include PII)

 Does not accept any insurance
 Not applicable, provides treatment free of
charge ➔ Thank you, please return
the questionnaire
6.
6.

12.
12.

As

accept
TRICARE
As of
oftoday,
today,does
does

accept
TRICARE
Select
in in
full?
Selectas
aspayment
payment
full?

 Yes
 No
 Don't Know

 Yes ➔ Go to Question 7
 No ➔ Go to Question 8
 Don't Know ➔ Go to Question 7

Thank you for taking the time to complete this survey. Please
put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to DataStat at
1-734-663-9084. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the
TRICARE web site at www.tricare.mil for assistance.

*001-00001*
DSW-00469-02
528-01

As of today, is accepting new

patients?
As
of today, is accepting new
patients?

01

DSWBH