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Manager, TRICARE Provider Certification
(Appropriate TRICARE
Claims Processor’s Address)
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Dear Manager:
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The Director, Defense Health
Agency (DHA), has authorized exceptions, on a case-by-case basis,
to the TRICARE policy which excludes any civilian employee of VHA
from authorization as a TRICARE provider. This letter identifies
the individual VHA employee(s) for
whom an exception is requested based on my determination that an
exception is required to avoid a detrimental effect on VHA’s
ability to obtain the necessary part-time physician employee(s) essential
to the mission of this facility. By granting this exception, the
individual part-time physician employee will be an authorized TRICARE
physician and may file claims for services furnished in the physician’s
private, non-VHA employment practice.
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A request for an exception
to TRICARE policy is made for the following part-time VHA
physician employee(s):
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(List each physician’s
name, specialty, address, and the physician’s IRS/SSAN or other
identification number used to report income to the Internal Revenue
Service.)
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In support of this request
for exception to policy, the individual physician(s) named have
signed the attached certification, as part of the physician’s application
for authorization as a TRICARE provider, that:
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1. The physician
understands the prohibitions against dual compensation under Title
5, United States Code (USC), Section 5536, as well as the standards
of conduct provisions applicable to Government employees who require
the avoidance of actual conflict of interest situations as well
as situations in which the appearance of conflict of interest may
exist; and
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2. The physician
has not violated the dual compensation or standard of conduct provisions
in providing any service(s) for which a TRICARE claim is submitted
for payment. This certification shall be retained on file by the
TRICARE claims processor and be applicable to all claims for services
of the physician during the period of authorization as a TRICARE
provider under this requested exception. In addition, when filing
individual TRICARE claims, the physician shall annotate the signature
block (Block 33) of the TRICARE claims form with the words “additional
certification on file” in order to identify the claim as an exception
to the general TRICARE policy and confirming that the certification
on file applies specifically to that claim.
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By requesting an exception
to TRICARE policy, I agree that the administrators of this VHA
facility shall assume full responsibility for informing the above-named
part-time physician employee(s) of the dual compensation and standard
of conduct provisions and for monitoring the conduct of the employee(s) and
enforcing the provisions regarding any TRICARE claims for service
furnished by the employee(s) while acting under this request for
exception to policy. In addition, for the above-named part-time physician
employee(s), I agree to provide the appropriate TRICARE claims processor
written notice of termination of VHA
employment or any other basis for withdrawal of this request for
exception to TRICARE policy.
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Thank you for your prompt attention
to this request. Should there be a need to contact VHA
regarding this request or regarding any matter arising out of the
implementation of this request, my point of contact on this matter
is ______________ who may be contacted at the above address or by
telephone number __________________.
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Sincerely,
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VHA
Facility Administrator
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Enclosure:
Physician’s Certification
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