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TRICARE Policy Manual 6010.63-M, April 2021
Chapter 11
Addendum D
Participation Agreement For Inpatient/Residential Substance Use Disorder Rehabilitation Facility (SUDRF) Services For TRICARE Beneficiaries
Facility Name:
Provider EIN:
Provider NPI:
Name of POC:
Defense Health Agency
16401 East Centretech Parkway
Aurora, Colorado 80011-9066
Article 1
This Participation Agreement is between the United States of America (USA) through the Department of Defense (DoD), Defense Health Agency (hereinafter DHA), the administering activity for the TRICARE and ______________________________ (hereinafter designated the SUDRF).
The implementing regulation for the TRICARE, 32 Code of Federal Regulations (CFR), Part 199, provides for TRICARE cost-sharing of care in inpatient/residential SUDRFs under certain conditions.
It is the purpose of this Participation Agreement to recognize the undersigned SUDRF as a TRICARE-authorized provider of inpatient/residential SUDRFs care, subject to the terms and conditions of this agreement and applicable federal law and regulation.
Article 2
The authorized representative(s) of the Director, DHA, or designee, may include, but are not limited to, DHA staff, DoD personnel, and DHA contractors, such as private sector accounting/audit firm(s) and/or utilization review and survey firm(s). Authorized representatives will be specifically designated as such.
The billing number for all substance use treatment is the SUDRF’s Employer’s Identification Number (EIN). In most situations, each EIN must enter into a separate Participation Agreement with the Director, DHA, or designee. This number must be used until the provider is officially notified by Director, DHA, or a designee, of a change. The SUDRF’s billing number is shown on the face sheet of this agreement.
For inpatient services, an admission occurs upon the formal acceptance by the SUDRF of a TRICARE beneficiary for the purpose of occupying a bed with the reasonable expectation that the patient will remain at least 24 hours, and with the registration and assignment of an inpatient number or designation. A discharge occurs at the time that the SUDRF formally releases the patient from inpatient status; or when the patient is admitted to any other inpatient setting, (e.g., an acute mental or medical hospital. For inpatient services, the day of admission is considered a day of care for payment purposes; the day of discharge is not.
For this agreement, a mental disorder shall be the definition in the TRICARE regulation 32 CFR 199.2): For the purpose of payment of benefits, a mental disorder is a nervous or mental condition that involves a clinically significant behavioral or psychological syndrome or pattern that is associated with a painful symptom, such as distress, and that impairs a patient’s ability to function in one or more major life activities. A Substance Use Disorder (SUD) is a mental condition that involves a maladaptive pattern of substance use leading to clinically significant impairment or distress; impaired control over substance use; social impairment; and risky use of a substance(s). Additionally, the mental disorder must be one of those conditions listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and billed with the corresponding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). “Conditions Not Attributable to a Mental Disorder,” or V codes (Z codes in the ICD-10-CM), are not considered diagnosable mental disorders. Co-occurring mental and SUDs are common, and assessment should proceed as soon as it is possible to distinguish the substance related symptoms from other independent conditions.
As defined in 32 CFR 199.6, SUDRFs are defined as free-standing facilities or hospital-based units that provide treatment of SUDs. SUDRFs can provide substance use treatment through inpatient rehabilitation programs on a 24-hour, seven-day-per week basis; through partial hospitalization in day, evening, or weekend programs. SUDRFs are differentiated from:
Acute psychoactive substance use treatment and from treatment of acute biomedical/mental health problems; which problems are either life-threatening and/or severely incapacitating and often occur within the context of a discrete episode of addiction-related biomedical or psychiatric dysfunction;
A Partial Hospitalization Program (PHP), as defined in 32 CFR 199.2, which serves patients who exhibit emotional/behavioral dysfunction but who can function in the community for defined periods of time with support in one or more of the major life areas (see the TRICARE Policy Manual (TPM), Chapter 11, Addendum F for the PHP Participation Agreement);
An Intensive Outpatient Program (IOP), as defined in 32 CFR 199.2, which serves patients in a day or evening program not requiring 24-hour care for mental health or SUD (see TPM, Chapter 11, Addendum G for the IOP Participation Agreement);
An Opioid Treatment Program (OTP), as defined in 32 CFR 199.2, which serves patients in a treatment setting for opioid treatment (see TPM, Chapter 11, Addendum H for the OTP Participation Agreement);
A group home, sober-living environment, halfway house, or three-quarter way house;
Therapeutic schools, which are educational programs supplemented by addiction-focused services;
Facilities that treat patients with primary psychotic diagnoses other than psychoactive substance use or dependence;
Facilities that care for patients with the primary diagnosis of intellectual disability or developmental disability.
Article 3
Performance Provisions
The SUDRF agrees to render treatment of SUDs to eligible TRICARE beneficiaries in need of such services, in accordance with this Participation Agreement and the TRICARE regulation (32 CFR 199). These services shall include board, routine nursing services, ancillary services, patient assessment, psychological testing, case management, and all mental health treatment determined necessary and consistent with the treatment plan established for the SUDRF patient, and accepted by Director, DHA, or designee.
The SUDRF agrees that all certifications and information provided to the Director, DHA, or designee, incident to the process of obtaining and retaining authorized provider status is accurate and that it has no material errors or omissions. In the case of any misrepresentations, whether by inaccurate information being provided or material facts withheld, authorized provider status will be denied or terminated, and the SUDRF will be ineligible for consideration for authorized provider status for a two year period. Termination of SUDRF status will be pursuant to Article 12 of this agreement.
On October 1, 1995, the SUDRF will not be considered to be a TRICARE-authorized provider nor will any TRICARE benefits be paid to the facility for any services until the date the Participation Agreement is signed by the Director, DHA, or designee.
The SUDRF agrees to limit charges to the rates set forth in this agreement.
The SUDRF agrees to charge only for services to TRICARE beneficiaries that qualify within the limits of law and regulation, including but not limited to the requirements that the care be medically or psychologically necessary as defined by DHA, and all terms of this agreement.
The SUDRF hereby agrees to:
Be licensed to provide substance use treatment within the applicable jurisdiction in which it operates, if licensure is available.
Be specifically accredited by and remain in compliance with standards issued by the Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the Director, DHA. The contractor may submit (via the Government Designated Authority (GDA)) additional organizations for TRICARE authorization.
Accept the TRICARE-determined rate, as provided in 32 CFR 199.14(a)(1)(ii)(F) for inpatient services, as payment in full for services provided.
Comply with all requirements of 32 CFR 199.4 applicable to institutional providers generally concerning preauthorization, concurrent care review, claims processing, beneficiary liability, double coverage, utilization and quality review, and other matters.
Ensure that any individual, group, or family psychotherapy, or psychological testing and assessment, is provided by a qualified mental health provider who meets TRICARE requirements for individual professional providers. (Exception: SUDRFs that employ individuals with master’s or doctoral level degrees in a mental health discipline who do not meet the licensure, certification, and experience requirements for a qualified mental health provider, but are actively working toward licensure or certification, may provide mental health services within the all-inclusive per-diem rate, but the individual must work under the direct clinical supervision of a fully qualified mental health provider employed by the SUDRF). All other program services will be provided by trained, licensed staff.
Ensure the provision of individual, group, and family psychotherapy and addiction counseling services that are consistent with each patient’s treatment plan.
Not bill the beneficiary for services in excess of the cost-share or services for which payment is disallowed for failure to comply with requirements for preauthorization.
Not bill the beneficiary for services excluded on the basis of 32 CFR 199.4(g)(1) (not medically or psychologically necessary), (g)(3) (inappropriate level of care), or (g)(7) (custodial care), unless the beneficiary has agreed in writing to pay for the care, knowing the specific care in question had been determined to be noncovered by TRICARE. (A general statement signed at admission relative to financial liability does not fill this requirement.)
Prior to initiation of this agreement, and annually thereafter, conduct a self-assessment of its compliance with the TRICARE/CHAMPUS Standards for Inpatient Rehabilitation and Partial Hospitalization for the Treatment of SUDs as issued by the Director, DHA, or designee, and notify the Director, DHA, or designee, of any matter in which the facility is not in compliance with such standards.
The SUDRF shall assure that any and all eligible beneficiaries receive substance use treatment that complies with the standards in Article 3.3.
The SUDRF shall provide substance use treatment in the same manner to TRICARE beneficiaries as it provides to all patients to whom it renders services.
The SUDRF shall not discriminate against TRICARE beneficiaries in any manner including admission practices, placement in special or separate wings or rooms, or provisions of special or limited treatment.
The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form for outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.
Under the terms of this agreement, the SUDRF shall:
Appoint a single individual within the facility to serve as the point of contact for conducting utilization review activities with Director, DHA, or its designee. The SUDRF will inform DHA in writing of the designated individual.
Obtain preauthorization for all inpatient services to be rendered to TRICARE beneficiaries within the facility.
Promptly provide medical records and other documentation required in support of the utilization review process upon request by Director, DHA, or its designee. Confidentiality considerations are not valid reasons for refusal to submit medical records on any TRICARE beneficiary. Failure to comply with documentation requirements will usually result in the denial of authorization of care.
Maintain and provide medical records, including the clinical formulation, progress notes, and master treatment plan, to include documentation of standardized assessment measures for Post-Traumatic Stress Disorder (PTSD), anxiety disorders, and depressive disorders using the PTSD Checklist (PCL-5), Generalized Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9 or A), respectively, at baseline, at 60 day intervals, and at discharge (see TPM, Chapter 1, Section 5.1 for details); in compliance with TRICARE standards and regulations.
Article 4
Payment Provisions
As specified in 32 CFR 199.14(a)(1)(ii)(F), effective for admissions on or after July 1, 1995, SUDRFs are subject to the Diagnosis-Related-Group-based (DRG-based) payment system for inpatient rehabilitation services.
All normally covered inpatient services furnished to TRICARE beneficiaries by hospitals are subject to the TRICARE DRG-based payment system. For inpatient rehabilitation care, professional services are reimbursed separately according to 32 CFR 199.14(a)(4).
No payment is due for leave days, for days on which treatment is not provided, or for days on which the patient is absent from treatment (whether excused or unexcused). The SUDRF must identify those days when claiming reimbursement.
Provided that there shall first have been a submission of claims in accordance with TRICARE procedures, the SUDRF shall be paid on the basis of the allowance of the rate determined in accordance with the controlling TRICARE regulation (see Article 4.1) contingent upon certain conditions provided in the TRICARE regulation, and in particular, the following:
The patient seeking admission is suffering from a mental disorder, to include SUD that meets both the diagnostic criteria of the current edition of the DSM and the TRICARE definition of a mental disorder.
The patient meets the criteria for admission to an SUDRF issued by the Director, DHA, or designee.
The medical and/or psychological necessity of the patient’s admission is determined by a qualified mental health provider who meets TRICARE requirements as an individual professional provider, and who is permitted by law and by the facility to refer patients for admission.
A qualified mental health professional who meets TRICARE requirements for individual professional providers will be responsible for the development, supervision, implementation, and assessment of a written, individualized, interdisciplinary clinical formulation and plan of treatment.
All individual, group, or family psychotherapy, and psychological testing and assessment are provided by or under the supervision of a qualified mental health provider who meets TRICARE requirements as an individual professional provider (see Article 3.3(h) above).
Director, DHA, or a designee, has preauthorized all inpatient or residential care rendered to the patient.
The patient meets eligibility requirements for TRICARE coverage.
The SUDRF agrees to accept the TRICARE rate determined pursuant to the TRICARE regulation (see Article 4.1) as the total charge for services furnished by the SUDRF to TRICARE beneficiaries. The SUDRF agrees to accept the TRICARE rate even if it is less than the billed amount, and also agrees to accept the amount paid by TRICARE, combined with the cost-share amount and deductible, if any, paid by or on behalf of the beneficiary, as full payment for the SUDRF services. The SUDRF agrees to make no attempt to collect from the beneficiary or beneficiary’s family, except as provided in Article 4.5(a), amounts for SUDRF services in excess of the TRICARE rate.
The SUDRF agrees to submit all claims as a participating provider. DHA agrees to make payment of the TRICARE-determined rate directly to the SUDRF for any care authorized under this agreement.
The SUDRF agrees to submit claims for services provided to TRICARE beneficiaries at least every 30 calendar days (except to the extent a delay is necessitated by efforts to first collect from Other Health Insurance (OHI)). If claims are not submitted at least every 30 calendar days, the SUDRF agrees not to bill the beneficiary or the beneficiary’s family for any amounts disallowed by TRICARE.
The SUDRF is subject to the provisions of 10 United States Code (USC), Section 1079(j)(1). The SUDRF must submit claims first to all other insurance plans and/or medical service or health plans under which the beneficiary has coverage before to submitting a claim to TRICARE.
Failure to collect first from primary health insurers and/or sponsoring agencies is a violation of this agreement, may result in the denial or reduction of payment, and may result in a false claim against the United States (US). It may also result in termination by DHA of this agreement pursuant to Article 12.
The SUDRF agrees to collect from the TRICARE beneficiary or the parents or guardian of the TRICARE beneficiary only those amounts applicable to the patient’s deductible and/or cost-share, as defined in 32 CFR 199.4 and services and supplies that are not a benefit of TRICARE.
The SUDRF’s failure to collect or to make diligent effort to collect the beneficiary’s cost-share as determined by TRICARE policy is a violation of this agreement, may result in the denial or reduction of payment, and may result in a false claim against the US. It may also result in termination by DHA of this agreement pursuant to Article 12 of this agreement.
If the SUDRF fails to abide by the terms of this Participation Agreement and Director, DHA, or its designee, either denies the claim or claims and/or terminates the agreement as a result, the SUDRF agrees to forego its rights, if any, to pursue the amounts not paid by TRICARE from the beneficiary or the beneficiary’s family.
Article 5
Records And Audit Provisions
The SUDRF grants the Director, DHA, or designee, the right to conduct on-site or off-site reviews or accounting audits with full access to patients and records. The audits will be conducted on a scheduled or unscheduled (unannounced) basis. This right to audit/review includes, but is not limited to the right to:
Examine fiscal and all other records of the SUDRF that would confirm compliance with this agreement and designation as a TRICARE-authorized provider.
Conduct audits of SUDRF records, including clinical, financial, and census records to determine the nature of the services being provided and the basis for charges and claims against the US for services provided to TRICARE beneficiaries. Director, DHA, or a designee, will have full access to records of both TRICARE and non-TRICARE patients. Note: In most cases, only TRICARE patients’ records will be audited. Examples of situations where non-TRICARE patient records would be requested may be in situations of differential quality of care assessments or to identify systemic quality or safety concerns.
Examine reports of evaluations and inspections conducted by federal, state, local Government, and private agencies and organizations.
Conduct on-site inspections of the facilities of the SUDRF and interviewing employees, members of the staff, contractors, board members, volunteers, and patients, as required.
Release copies of final review reports if requested under the Freedom of Information Act.
DHA and its authorized agents will have the authority to visit and inspect the SUDRF at all reasonable times on an unannounced basis.
The SUDRF’s records shall be available and open for review by DHA during normal working hours, from 8 a.m. to 5 p.m., Monday through Friday, on an unannounced basis.
Upon request, the SUDRF shall furnish Director, DHA, or a designee, the audited cost reports certified by an independent auditing agency.
Upon request, the SUDRF shall furnish Director, DHA, or a designee, with such records, including medical records and patient census records, that would allow Director, DHA, or a designee, to determine the quality and cost-effectiveness of care rendered.
Upon the provider’s completion of this participation agreement and the DHA Form 771, the contractor shall submit the information to the TRICARE Quality Monitoring Contractor (TQMC).
Failure to allow audits/reviews and/or to provide records constitutes a material breach of this agreement. It may result in the denial or reduction of payment, termination of this agreement pursuant to Article 12, and any other appropriate action by DHA.
Article 6
The SUDRF agrees to comply with the provisions of section 504 of the Rehabilitation Act of 1973 (Public Law 93-112; as amended) regarding nondiscrimination on the basis of handicap, and Title VI of the Civil Rights Act of 1964 (Public Law 88-352), the Americans With Disabilities Act of 1990 (Public Law 101-336), and Section 1557 of the Patient Protection and Affordable Care Act (PPACA) as well as all regulations implementing these Acts.
Article 7
The Director, DHA, or designee, or may amend the terms of this Participation Agreement by giving 120 days’ notice in writing of the amendment(s) except amendments to the TRICARE regulation, which shall be considered effective as of the effective date of the regulation change and do not require a formal amendment of this agreement to be effective. When changes or modifications to this agreement result from amendments to the TRICARE regulation through rulemaking procedures, the Director, DHA, or designee, is not required to give 120 days’ written notice. Amendments to this agreement resulting from amendments to the TRICARE regulation shall become effective on the date the regulation amendment is effective or the date this agreement is amended, whichever date is earlier.
The SUDRF, if it concludes it does not wish to accept the proposed amendment(s), including any amendment resulting from amendment(s) to the TRICARE regulation accomplished through rulemaking procedures, may terminate its participation as provided for in Article 12.3. However, if the SUDRF’s notice of intent to terminate its participation is not given at least 60 days before the effective date of the proposed amendment(s), then the proposed amendment(s) shall be incorporated into this agreement for SUDRF care furnished between the effective date of the amendment(s) and the effective date of termination of this agreement.
Article 8
Change Of Ownership
This agreement is nonassignable.
Unless otherwise extended as specified in Article 8.3(b), this agreement ends as of 12:01 a.m. on the date following the date that transfer of ownership occurs.
Change of Ownership is defined as follows:
The change in an owner(s) that has/have 50% or more ownership constitutes a change of ownership.
The merger of the SUDRF corporation (for-profit or not-for-profit) into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation, constitutes a change of ownership. The transfer of corporate stock or the merger of another corporation into the SUDRF corporation, however, does not constitute change of ownership. The transfer of title to property of the SUDRF corporation to another corporation(s), and the use of that property for the rendering of substance use treatment by the corporation(s) receiving it is a change of ownership.
The lease of all or part of a SUDRF or a change in the SUDRF’s lessee constitutes change of ownership.
If there is a change of ownership of a SUDRF as specified in Article 8.2(b), then the new owner, in order to be a TRICARE-authorized SUDRF must enter into a new agreement with DHA. The new owner is immediately subject to any existing plan of correction, expiration date, applicable health and safety standards, ownership and financial interest disclosure requirements, and any other provisions and requirements of this agreement.
A SUDRF contemplating or negotiating a change of ownership must notify the Director, DHA, or designee, in writing at least 30 days before the effective date of the change. At the discretion of the Director, DHA, or designee, this agreement may remain in effect until a new Participation Agreement can be signed to provide continuity of coverage for beneficiaries. A SUDRF that has provided the required 30 calendar days’ advance written notification of a change of ownership may seek an extension of this agreement’s effect for a period not to exceed 180 days from the date of the transfer of ownership. Failure to provide 30 days’ advance written notification of a change of ownership will result in a denial of a request for an extension of this agreement and the termination of this agreement upon transfer of ownership as specified in Article 8.2(a).
Prior to a transfer of ownership of a SUDRF, the new owners may petition the Director, DHA in writing for a new Participation Agreement. The new owners must document that all required licenses and accreditations have been maintained and must provide documentation regarding any program changes. Before a new Participation Agreement is executed, the Director, DHA, or designee, or will review the SUDRF to ensure that it is in compliance with TRICARE requirements.
Article 9
Any serious occurrence involving a TRICARE beneficiary, outside the normal routine of the SUDRF (see the TRICARE Operations Manual (TOM), Chapter 7, Section 6), must be reported to the referring military providers and/or Market/Military Medical Treatment Facility (MTF) referral management office (on behalf of the military provider), and DHA, and/or a designee, as follows:
An incident of a patient death, life-threatening accident, suicide attempt, patient disappearance, incident of cruel or abusive treatment, or any equally dangerous situation involving a TRICARE beneficiary, shall be reported by telephone on the next business day with a written report within seven days.
The incident and the following report shall be documented in the patient’s clinical record.
Notification shall be provided, if appropriate, to the parents, legal guardian, or legal authorities.
When a TRICARE beneficiary is absent without leave and is not located within 24 hours, the incident shall be reported by telephone on the next business day. If the patient is not located within three calendar days, a written report shall be made to DHA within seven calendar days.
Any disaster or emergency situation, natural or man-made, such as fire or severe weather, shall be reported telephonically within 72 hours, followed by a comprehensive written report within seven days to DHA.
The governing body or the administrator of the facility shall submit in writing to DHA, any significant proposed changes within the SUDRF no later than 30 days prior to the actual date of change. A report shall be made concerning the following items:
Any change in administrator or primary professional staff.
Any change in purpose, philosophy, or any addition or deletion of services or programs. This includes capacity or hours of operation
Any licensure, certification, accreditation, or approval status change by a state agency or national organization.
Any anticipated change in location or anticipated closure.
Any suspension of operations for 24 hours or more.
Article 10
General Accounting Office (GAO)
The SUDRF grants the US GAO the right to conduct audits.
Article 11
Appeals of DHA actions under this agreement, to the extent they present an appealable issue and are allowed under the TRICARE regulation, will be pursuant to 32 CFR 199.10 and 32 CFR 199.15.
Article 12
The Director, DHA, or designee, may terminate this agreement in accordance with procedures for termination of institutional providers as specified in 32 CFR 199.9.
In addition to any authority under the TRICARE regulation to terminate or exclude a provider, the Director, DHA, or designee, may terminate this agreement for cause, upon 30 days’ written notice, if the SUDRF:
Is not in compliance with the requirements of the Dependents Medical Care Act, as amended (10 USC 1071 et seq.), the TRICARE regulation (32 CFR 199), or with performance provisions stated in Article 3 of this Participation Agreement.
Fails to comply with payment provisions set forth in Article 4 of this agreement.
Fails to allow audits/reviews and/or to provide records as required by Article 5 of this agreement.
Fails to comply with nondiscrimination provisions of Article 6 of this agreement.
Changes ownership as set forth in Article 8 of this agreement.
Fails to provide incident reports, disaster or emergency reports, or reports of SUDRF changes, as set forth in Article 9 of this agreement.
Initiates a program change without written approval by Director, DHA, or a designee; program changes include but are not limited to: changes in the physical location, population served, capacity, type of license, expansion of program(s), or development of new program(s).
Does not admit a TRICARE beneficiary during any consecutive 24-month period.
Suspends operations for a period of 120 days or more.
Is determined to be involved in provider fraud or abuse, as established by TRICARE regulation (32 CFR 199.9). This includes the submission of falsified or altered TRICARE claims or medical records which misrepresent the type, frequency, or duration of services or supplies.
The Director, DHA, or designee, may terminate this agreement without prior notice in the event that the SUDRF’s failure to comply with the industry standards for inpatient/residential SUDRFs presents an immediate danger to life, health, or safety.
The SUDRF may terminate this agreement by giving the Director, DHA, or designee, written notice of such intent to terminate. The effective date of a voluntary termination under this article shall be 60 calendar days from the date of notification of intent to terminate, or upon written request, as agreed between the SUDRF and DHA.
Article 13
DHA will have the authority to suspend claims processing or seek recoupment of claims previously paid as specified under the provisions of the Federal Claims Collection Act (31 USC 3701 et seq.), the Federal Medical Care Recovery Act (42 USC 2651-2653), and 32 CFR 199.
Article 14
Order Of Precedence
If there is any conflict between this agreement and any Federal statute or Federal regulation, including the TRICARE regulation, 32 CFR 199, the statute or regulation controls.
Article 15
This agreement will remain in effect up to five years from the effective date (see Article 16) unless terminated earlier by DHA or the SUDRF under Article 12. DHA may extend this agreement for 60 days beyond the established date if necessary to facilitate a new agreement.
The SUDRF must reapply after the automatic expiration of this agreement if it wishes to continue as a TRICARE-authorized SUDRF. Failure to reapply will result in the automatic expiration of this agreement on the date specified in Article 17.
Article 16
Effective Date
This Participation Agreement will be effective on the date signed by the Director, DHA, or designee.
This agreement must be signed by the Chief Executive Officer (CEO) or designee of the SUDRF.
Article 17
Authorized Provider
On the effective date of the agreement, DHA recognizes the SUDRF as an authorized provider for the purpose of providing substance use treatment to TRICARE-eligible beneficiaries within the framework of the program(s) identified below.
Program Name
Expiration Date
By: Signature
By: Signature
Name and Title
Name and Title
Executed on: ____________________________
Executed on: ____________________________
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