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Get TRICARE HF0917x065 2017-2024

L Priority: Care must be rendered: Routine–must be seen within 28 days Urgent–must be seen within 72 hours* Service Type Q1 Q2 Q3 Requesting Provider Information Specialty Referral/Global Maternity Requesting Provider Telephone Number: ( ) Physical or Occupational Therapy Requesting Provider Fax Number: ( - OP Behavioral Health Contact Name: OP Medical Care/Procedure Requesting Provider/Facility Name: DME/Radiology ) - Physician State License #: Speech Therapy Outpatient S.

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