APPENDIX A-4 TRICARE-AUTHORIZED RESIDENTIAL TREATMENT CENTERS
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1 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 Following are the rate adjustments for those RTCs whose 1995 per diems were below the 30th percentile of all established fiscal year 1995 rates. The rates were adjusted by the lesser of the Consumer Price Index - Urban Wage Earners (CPI-U) for medical care for the annual reporting period of July 1, 1995, to July 1, 1996 (3.6 percent) or the amount that brought the rate up to the 30th percentile level ($429). These rates are for payment of services provided on or after October 1, NOTE: This listing is for residential treatment center per diem rates only. It does not reflect a facility s status as a TRICARE-authorized residential treatment center. Information regarding a facility s current status as an authorized provider can be obtained from the appropriate contractor. ALABAMA Charter BHS of Mobile, Inc Southland Center Mobile, AL Facility No EIN: Hillcrest Hospital BHS-AL 6869 Fifth Avenue South Birmingham, AL Facility No EIN: ARIZONA Wendy Paine O Brien Treatment CTR 5055 North 34th St. Phoenix, AZ Facility No EIN: (B) Desert Hills Ctr for Youth & Family 2797 N. Introspect Drive Tucson, AZ Facility No EIN: A4-1
2 APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 Westbridge RTC-Children & Adolescent 1830 E. Roosevelt Phoenix, AZ Facility No EIN: ARKANSAS CPC Pinnacle Pointe Hospital RTC Financial Center Parkway Little Rock, AR EIN: CALIFORNIA Broad Horizons P.O. Box H Street Ramona, CA Facility No EIN: CPC San Luis Rey Hospital 345 Saxony Road Encinitas, CA Facility No EIN: San Diego Center for Children 3002 Armstrong Street P.O. Box San Diego, CA Facility No EIN: Vista San Diego Center 3003 Armstrong Street San Diego, CA Facility No EIN: A4-2
3 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 COLORADO Brockhurst Extended Care Program P.O. Box E. Pikes Peak Colorado Springs, CO Facility No EIN: Cheyenne Mesa 1301 South 8th Street Colorado Springs, CO Facility No EIN: Cedar Springs Hospital, Inc Southgate Road Colorado Springs, CO Facility No EIN: FLORIDA Charter BHS at Medfield Seminole Boulevard Largo, FL Facility No EIN: CPC Palm Bay Hospital 4400 Dixie Hwy NE Palm Bay, FL EIN: La Amistad RTC 201 Alpine Drive Maitland, FL Facility No EIN: A4-3
4 APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 Valuemark Laurel Oaks BHS, Inc 6601 Central Florida Parkway Orlando, FL Facility No EIN: Charter BHS at Manatee Palms st Street Bradenton, FL Facility No. EIN: Rivendell of Fort Walton Beach 1015 Mar Walt Drive FT. Walton Beach, FL Facility No EIN: Tampa Bay Academy Boyette Road Riverview, FL Facility No EIN: CPC St. Johns River Hospital CRC 6300 Beach Blvd. Jacksonville, FL EIN: University Behavioral Center 2500 Discovery Drive Orlando, FL EIN: GEORGIA Charter BHS of Atlanta at Laurel Heights 934 Briarcliff Road, N.E. Atlanta, GA Facility No EIN: A4-4
5 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 Charter Augusta BHS 3100 Perimeter Parkway Augusta, GA EIN: HAWAII Sutten Health Pacific DBA Kahi Mohala Fort Weaver Road Ewa Beach, HI Facility No EIN: IDAHO CPC Intermountain Hospital of Boise 303 N. Allumbaugh Street Boise, ID Facility No EIN: INDIANA Charter BHS of Indiana at Jefferson 2700 River City Park Jeffersonville, IN EIN: KANSAS CPC College Meadows Hospital RTC College Boulevard Lenexa, KS Facility No. EIN: The Menninger Clinic RTC 5800 S.W. Sixth Topeka, KS EIN: A4-5
6 APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 St. Francis at Salina, Inc West Cloud Street Salina, KS EIN: LOUISIANA DePaul Hospital 1040 Calhoun Street New Orleans, LA Facility No EIN: MISSISSIPPI CPC Sand Hill Hospital RTC Program Highway 49 North Gulfport, MS EIN: MISSOURI Heartland Behavioral Health Svcs 1500 W. Ashland Nevada, MO Facility No EIN: Piney Ridge Center, Inc Hospital Road P.O. Box 4067 Waynesville, MO Facility No EIN: NEVADA BHC Willow Springs Center 690 Edison Way Reno, NV Facility No EIN: A4-6
7 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 NEW MEXICO Desert Hills Ctr for Youth & Family 5310 Sequoia, N.W. Albuquerque, NM Facility No. EIN: NORTH CAROLINA Cumberland Hospital 3425 Melrose Road P.O. Box (28309) Fayetteville, NC Facility No EIN: OKLAHOMA Shadow Mountain Hospital 6262 South Sheridan Road Tulsa, OK Facility No EIN: SOUTH CAROLINA Charter of Charleston BHS 2777 Speissegger Drive Charleston, SC EIN: TENNESSEE Charter Lakeside BHS 2911 Brunswick Road P.O. Box Memphis, TN Facility No EIN: Pine Point Center 49 Old Hickory Blvd. Jackson, TN EIN: A4-7
8 APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 TEXAS BHC Cedar Crest 3500 South IH 35 Belton, TX Facility No EIN: CRC of San Antonio Corporate Woods Drive San Antonio, TX EIN: CPC Millwood Hospital & CRC 1011 North Cooper Arlington, TX Facility No EIN: Healthcare Rehabilitation Center of Austin Box West Dittmar Austin, TX Facility No EIN: Laurel Ridge Hospital Corporate Woods Drive P.O. Box San Antonio, TX Facility No EIN: (D) Meridell Achievement Center Highway 29 West P.O. Box 87 Liberty Hill, TX Facility No EIN A4-8
9 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 San Marcos Treatment Center Bert Brown Road P.O. Box 768 San Marcos, TX Facility No EIN: (B) Southwest Mental Health Center 8538 Tom Slick Drive San Antonio, TX Facility No EIN: Devereux Foundation - Victoria Box David Wade Drive Victoria, TX Facility No EIN: (D) The Oaks Treatment Center 1407 West Stassney Lane Austin, TX Facility No EIN: (C) Quest Hospital Adolescent RTC 7200 West 9th Avenue Amarillo, TX Facility No.: EIN: UTAH CPC Olympus View Community Res Cntr 1430 East 4500 Salt Lake City, UT Facility No. EIN: A4-9
10 APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 Rivendell of Utah 5899 West Rivendell Drive West Jordon, UT Facility No EIN: VERMONT Brattleboro Retreat-Tyler RTC 75 Linden Street Brattleboro, VT EIN: VIRGINIA Charter Westbrook BHS 1500 Westbrook Avenue PO Box 9127 Richmond, VA EIN: Poplar Springs 350 Poplar Drive Petersburg, VA EIN: Valuemark - West End BHS West Creek Pkwy Richmond, VA Facility No EIN: The Pines Treatment Center 825 Crawford Parkway Portsmouth, VA Facility No EIN: (B) A4-10
11 TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 APPENDIX A-4 WASHINGTON Community Residential Center at Fairfax N.E. 132nd Street Kirkland, WA EIN: Tamarack Center 2901 West Fort George Wright Spokane, WA EIN: A4-11
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APPENDIX A-6 TRICARE-AUTHORIZED RESIDENTIAL TREATMENT CENTERS
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-6 For payment of services provided on or after October 1, 1998. NOTE: This listing is for residential treatment center per diem rates only. It
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