Military Health System

In order to receive payment under the TRICARE, _____________________________________________ _________________________ ___________ dba ____________________________________________ as the provider of services agrees:

To accept as payment for inpatient services provided to eligible beneficiaries, the allowable amount under TRICARE will be determined in accordance with the requirements of 32 CFR 199.

To refrain from billing the TRICARE-eligible beneficiary for amounts which exceed the allowable amount under TRICARE except for services not covered by TRICARE as described in 32 CFR 199 and for amounts which constitute the TRICARE beneficiary’s liability for cost-share and deductible.

To pay hospital the full allowable amount less any applicable cost-share and deductible amounts.

This agreement shall be binding on the provider and DHA upon submission by the provider of acceptable assurance of compliance with Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973 as amended, and upon acceptance by the Deputy Director, DHA, or his designee.

This agreement shall be effective until terminated by either party. The effective date shall be the date the agreement is signed by DHA.

The agreement may be terminated by either party by giving the other party written notice of termination. Such notice of termination is to be received by the other party no later than 30 days prior to the date of termination. In the event of transfer of ownership, this agreement is assigned to the new owner, subject to the conditions specified in this agreement and pertinent regulations.

For Provider Of Services By:

For Defense Health Agency By:

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