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LC-7564-4 ROA Page 1 of 2 07/2013 Important - Please read the statement that applies to your state of residence. Reserve Officers Association Health Insurance Claim Form Before completing please read all instructions carefully to insure fast accurate processing* INSTRUCTIONS ON HOW TO SUBMIT A CLAIM FORM 1. The form must be completed with all requested information* Sign and date the reverse side of form* 2. Complete Section 2 only if you want us to pay your insurance benefits to the provider...
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Fill in your social security number and the date of birth as requested.
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Provide details of the referring and attending providers, including their names, addresses, and any other relevant information.
05
Indicate the nature of the medical service or treatment received and the dates on which they were rendered.
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Individuals who have received medical services covered by Tricare, such as current and former military members, their dependents, and retirees.
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lc-7363-0 Tricare statement is a form that provides information about healthcare services provided to Tricare beneficiaries.
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Healthcare providers that rendered services to Tricare beneficiaries are required to file lc-7363-0 Tricare statement.
How to fill out lc-7363-0 tricare statement of?
To fill out lc-7363-0 Tricare statement, providers need to provide information regarding the services rendered, including dates, codes, charges, and any supporting documentation.
What is the purpose of lc-7363-0 tricare statement of?
The purpose of lc-7363-0 Tricare statement is to report healthcare services provided to Tricare beneficiaries for reimbursement and claims processing.
What information must be reported on lc-7363-0 tricare statement of?
lc-7363-0 Tricare statement must include information such as the beneficiary's identification, provider information, service dates, procedure and diagnosis codes, charges, and any supporting documentation.
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