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Get DD 2870 2003-2024

T in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization. I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above to the named individual/organization indicated. 11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE 12. RELATIONSHIP TO PATIENT (If applicable) 13. DATE (YYYYMMDD) SECTION IV - FOR STAFF USE O.

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