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10/19/2022 3:44:26 PM -0500 CENTRAL TIME CNC 8337280092
PAGE 2
OF 3
HEALTH NET
hnfs FEDERAL SERVICES
A Wholly Owned Subsidery of Centene Corporation
TRICARE
Date: October 19, 2022
Before
you submit
your next request for
services, please visit
www.tricare-west.com. Our online
referral and authorization tool returns
an immediate response!
It's easy to register:
https://www.tricare-west.com/content/
hnfs/home/tw/prov/registration.html
NORTHERN HILLS EYE CARE
910 HARMON ST
STURGIS, SD 57785 2556
Date of Birth:
10/27/2014
Patient ID:
XXXXX9059
Beneficiary Name:
Beneficiary Phone Number:
Sponsor Name:
Beneficiary Plan Type:
Servicing Provider Phone:
NAME_1
************
NAME_2
TRICARE Prime-Active Duty Family
Members
605-347-2666
Health Net Federal Services, LLC (HNFS) has approved the following services for the above TRICARE
beneficiary.
Reference Number: 20222920011695943
Request Priority: Elective/Routine
Provider Specialty: Optometrist
Diagnosis 1: H00.019
Hordeolum externum unspecified eye, unspecified eyelid
Service Type Service Codes
Service Dates
Visits/Units
99202* 99205
10/19/2022 - 04/17/2023
1
Office Visit
Professional
99211*99215
10/19/2022 - 10/19/2023
Office Visit
Professional
99241*99245 10/19/2022 - 04/17/2023
1
Office Visit
Professional
*
(99202)
Office or other outpatient visit for the evaluation and management of a new patient, which
requires a medically appropriate history and/or examination and straightforward medical
decision making. When using time for code selection, 15-29 minutes of total time is spent on the
date of the encounter.
This document may contain information covered under the Privacy Act (5 USC §552a) and/or the Health Insurance Portability and
Accountability Act (P.L.104-191) and its various implementing regulations and must be protected in accordance with those provisions.
If you have received this correspondence in error, please notify 844-866-WEST (866-9378) at once and destroy the documents and
any copies you have made.
Authorizations and Referrals • P.O. Box 9108 Virginia Beach, VA 23450-9108
TRICARE is a registered trademark of the Department of Defevise, Defense Mealth Agency. All rights reserved.
1502001

```

Dont change the name order. If the content is a fax cover page then no need to extract any things only return {}
Extract exact Patient name key and value?
Extract exact Patient date of birth key and value?
Extract exact provider name key and value?

Answer should be in a json formate. and must be comma separated all the key value pair.
{
"patient_n Provide the entire answer in JSON format.
user