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Get TP-1568.6 2012-2024

Dress: Physician Signature: I hereby affirm that I have been informed and I understand that these services are excluded or excludable under the TRICARE Program and therefore all costs associated with these services are not an allowable expense under The TRICARE Program. By signing the TRICARE non-covered services waiver, I am hereby agreeing in advance, in writing, to accept full financial responsibility for all costs associated with the non-covered medical services, described in this document .

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