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Get LC-7363-0 TRICARE Statement Of Claim & Auth To Release ... - EBView

IM FORM 1. The form must be completed with all requested information. Please sign and date the reverse side of form. 2. Complete Section 2 only if you want us to pay your insurance benefits to the provider (for example, doctor, clinic, hospital, etc.) 3. Enclose a copy of your TRICARE Explanation of Benefits form. Put your certificate number on the copy. 4. For TRICARE Supplements, if services were provided in a Civilian Hospital, please attach a copy of the TRICARE Explanation of Benefits Form.

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