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Get MOAA LC-7564 2012

E 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; if services were provided in a Government Hospital, a copy of your Subsistence Receipt is needed; If you have TRICARE Prime Coverage, please submit a copy of your bill showing amount of charges and also the copayment amount. 5. If your claim for benefits is under the MOAA Hospital I.

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