AUTHORIZED PROVIDER. 17.1 PROVIDER STATUS On the effective date of the agreement, DHA recognizes the IOP as an authorized provider for the purpose of providing intensive outpatient care to eligible beneficiaries within the framework of the program(s) identified below. INTENSIVE OUTPATIENT PROGRAM (IOP) NAME(S) CAPACITY AGE RANGE DAYS OF OPERATION Intensive Outpatient Program (IOP) Facility Name Expiration Date DHA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. 18.1 TRICARE-PROVIDER STATUS On the effective date of the agreement, DHA recognizes the RTC as an authorized provider for the purpose of providing RTC care to TRICARE-eligible beneficiaries within the framework of the program(s) identified below. PROGRAM BEDS AGES Residential Treatment Center Name Expiration Date TRICARE Per Diem Rate DHA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. 17.1 PROVIDER STATUS On the effective date of the agreement, DHA recognizes the OTP as an authorized provider for the purpose of providing opioid treatment to eligible beneficiaries within the framework of the program(s) identified below. OPIOID TREATMENT PROGRAM (OTP) NAME(S) CAPACITY AGE RANGE DAYS OF OPERATION Opioid Treatment Program (OTP) Facility Name Expiration Date DHA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. 12.1 DATE RECOGNIZED On the effective date of the agreement, DHA recognizes the BC as an authorized provider for purposes of providing BC services to TRICARE eligible beneficiaries. Birthing Center By: Signature Typed Name Typed Title Executed on , DHA By: Signature Typed Name Typed Title Executed on ,
AUTHORIZED PROVIDER. 17.1 TRICARE-PROVIDER STATUS 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 AGES BEDS SUDRF Name Expiration Date DHA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. On the effective date of the agreement, TMA 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 AGES BEDS Substance Use Disorder Rehabilitation Facility Name Expiration Date TMA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. 18.1 PROVIDER STATUS On the effective date of the agreement, DHA recognizes the PHP as an authorized provider for the purpose of providing psychiatric partial hospitalization care to eligible beneficiaries within the framework of the program(s) identified below. PSYCHIATRIC PARTIAL HOSPITALIZATION PROGRAM NAME(S) CAPACITY AGE RANGE DAYS OF OPERATION HALF-DAY (HD) FULL-DAY (FD) Partial Hospitalization Facility Name Expiration Date Defense Health Agency By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. On the effective date of the agreement, TMA recognizes the BC as an authorized provider for purposes of providing birthing center services to TRICARE eligible beneficiaries. Birthing Center By: Signature Typed Name Typed Title Executed on , TMA By: Signature Typed Name Typed Title Executed on ,
AUTHORIZED PROVIDER. On the effective date of the agreement, TMA recognizes the RTC as an authorized provider for the purpose of providing residential treatment center care to TRICARE-eligible beneficiaries within the framework of the program(s) identified below. PROGRAM BEDS AGES Residential Treatment Center Name Expiration Date TRICARE Per Diem Rate TMA By: Signature By: Signature Name and Title Name and Title Executed on: Executed on:
AUTHORIZED PROVIDER. 18.1 PROVIDER STATUS On the effective date of the agreement, TMA recognizes the PHP as an authorized provider for the purpose of providing psychiatric partial hospitalization care to eligible beneficiaries within the framework of the program(s) identified below.
