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TRICARE Beneficiary Liability Form Waiver of Non-Covered Services This waiver allows a network contracted provider to collect billed charges for services denied as non-covered from a TRICARE beneficiary when the beneficiary has agreed in writing to waive his or her balance-billing protection. I the TRICARE beneficiary hereby agree to pay up to the full billed charge s for the following service s if such service is subsequently denied as non-covered regardless of the fact the TRICARE program will not make payment Date Service Code Estimated Billed Charge TOTAL ESTIMATED BILLED CHARGES Note This waiver applies to any and all TRICARE non-covered services indicated above rendered by this provider including but not limited to office visits office procedures hospital visits and surgical fees. I acknowledge that I am signing this statement voluntarily and that it is not being signed under duress or after the services have already been provided* I understand that by signing this form I will be fully responsible for the total billed charge s for any services denied as non-covered and listed above and will pay the provider this amount regardless of the fact TRICARE will not make payment. I also understand that it is my choice to have these services provided at a future date and time by this provider. TRICARE BENEFICIARY SIGNATURE DATE SPONSOR SSN RELATIONSHIP TO SPONSOR Providers must follow all applicable coding regulations. If an appropriate CPT code exists that covers several procedures rendered the provider must use the all-inclusive procedure code and not bill for each procedure separately. PROVIDER INFORMATION NAME ADDRESS CITY ST ZIP CODE PHONE NUMBER Privacy Act Statement - This information is protected under the Privacy Act of 1974 and shall be handled as for official use only. I acknowledge that I am signing this statement voluntarily and that it is not being signed under duress or after the services have already been provided* I understand that by signing this form I will be fully responsible for the total billed charge s for any services denied as non-covered and listed above and will pay the provider this amount regardless of the fact TRICARE will not make payment. I also understand that it is my choice to have these services provided at a future date and time by this provider. I also understand that it is my choice to have these services provided at a future date and time by this provider. TRICARE BENEFICIARY SIGNATURE DATE SPONSOR SSN RELATIONSHIP TO SPONSOR Providers must follow all applicable coding regulations. TRICARE BENEFICIARY SIGNATURE DATE SPONSOR SSN RELATIONSHIP TO SPONSOR Providers must follow all applicable coding regulations. If an appropriate CPT code exists that covers several procedures rendered the provider must use the all-inclusive procedure code and not bill for each procedure separately. If an appropriate CPT code exists that covers several procedures rendered the provider must use the all-inclusive procedure code and not bill for each procedure separately. PROVIDER INFORMATION NAME ADDRESS CITY ST ZIP CODE PHONE NUMBER Privacy Act Statement - This information is protected under the Privacy Act of 1974 and shall be handled as for official use only. .

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