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Get FL TRICARE RTC Placement Application 2013-2021

Insurance: Yes* No *If yes, please specify: Patient’s current placement: Home Other family Hospital Foster Setting Zip: Juvenile Detention RTC APPLICATION INSTRUCTIONS This application must be completed, legible, and signed by the current treating Physician or Clinical Psychologist (PsyD or PhD). No other licensed clinicians can refer) who is recommending treatment in a RTC to avoid any delays. Information must be current and based on recent contact with the patient and family. Please fax .

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