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Iciary when the beneficiary has agreed, in writing, to waive his or her balance-billing protection. I, , the TRICARE beneficiary, hereby agree to pay up to the full billed charge(s) for the following service(s) if such service is subsequently denied as non-covered regardless of the fact the TRICARE program will not make payment: Date: Service (Code): Estimated Billed Charge: Date: Servi.

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