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In order to receive payment
under the TRICARE, _____________________________________________ _________________________
___________ dba ____________________________________________ as
the provider of services agrees:
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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.
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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.
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DHA agrees:
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To pay hospital the full allowable
amount less any applicable cost-share and deductible amounts.
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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.
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This agreement shall be effective
until terminated by either party. The effective date shall be the
date the agreement is signed by DHA.
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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.
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For Provider Of Services By:
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For Defense Health Agency By:
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Name
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Name
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Title
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Title
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Date
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Date
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