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TRICARE OVERSEAS PUERTO RICO PATIENT REFERRAL AUTHORIZATION FORM Please complete and submit this form by fax to 1-215-773-2701 SECTION I PATIENT INFORMATION Last Name First Name MI DOB Sponsor s SSN or DBN Phone Email Gender Address 1 Address 2 City State ZIP Code Yes SECTION II OTHER HEALTH INSURANCE No SECTION III REFERRAL INFORMATION Referred to Specialty type Provider/Facility Name Phone Fax Evaluation Only Evaluation Treat Service Quantity .

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