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Application for Residential Treatment Center – Family

This form must be filled out by the beneficiary (the parent or legal guardian) in order to have a child placed in a Residential Treatment Center. Health Net Federal Services, LLC will look at the request once we receive both the family application and the Provider RTC Application. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Jul 22, 2014
  • Modified: Dec 5, 2018
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