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Authorization to Disclose Medical or Dental Information

This form enables a beneficiary to authorize Health Net Federal Services, LLC (HNFS) or its subcontractor to release his or her medical information to a specified third party, for example, a spouse, relative or law firm.

Please note: Incomplete and/or unsigned forms will not be processed.

You may fax this form to 1-844-308-8877 or mail it to:

TRICARE Legal Documents
PO Box 8818
Virginia Beach, VA 23450-8818

  • Created: Jun 6, 2018
  • Modified: Jun 6, 2018
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