Form ddx605 TRICARE YOUNG ADULT APPLICATION

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TRICARE YOUNG ADULT APPLICATION

The public reporting burden for this collection of information is estimated to average XX per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN

COMPLETED FORM TO THE FOLLOWING SERVICING CONTRACTOR:

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. Chapter 17, Hospital, Nursing Home, Domiciliary, and Medical Care; 32
CFR Part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); 45 CFR Parts 160 and 164, Health Insurance Portability
and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSES: To obtain information to permit certain former military health care beneficiaries to purchase, transfer, or terminate extended
dependent health care coverage under the TRICARE Young Adult Program.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these records
may specifically be disclosed outside the Department of Defense as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to the Departments of
Veterans Affairs, Health and Human Services and Homeland Security, and to other Federal, State, local, or foreign government agencies, and to
private business entities, including entities under contract with the Department of Defense and individual providers of care, on matters relating to
eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability,
coordination of benefits, and civil or criminal litigation.
DISCLOSURE: Voluntary; however, failure to furnish all requested information may result in denial of the individual's purchase, transfer, or
termination of TRICARE Young Adult Program health plan coverage.
1. TRICARE COVERAGE DESIRED (X one. Based on Uniformed Service sponsor's status.)
TRICARE Standard
TRICARE Prime (where available and if qualified)
TRICARE Overseas Prime (dependent must be command sponsored and meet specific enrollment criteria of the overseas area)
TRICARE Reserve Select (sponsor must be enrolled in TRS)
TRICARE Prime Remote for Active Duty Family Members
(sponsor must be enrolled in TPR)

TRICARE Retired Reserve (sponsor must be enrolled in TRR)
Uniformed Services Family Health Plan (where available and if
qualified)
3. REQUESTED EFFECTIVE/TERMINATION/TRANSFER
DATE (YYYYMMDD)

2. REQUESTED ACTION (X one)
Start coverage (complete all items)
Terminate TYA coverage (complete items 2 - 10, 12-15, and 17):
Have employer-sponsored healthcare

Marriage

Voluntary

Transfer coverage to another TYA Plan (complete items 2 - 10, 11 as needed, and 17). If necessary, recurring monthly premiums will be
adjusted accordingly.
APPLICANT INFORMATION
5. SOCIAL SECURITY NUMBER (SSN)
OR DoD BENEFITS NUMBER (If known)

4. NAME (Last, First, Middle Initial)

6. DATE OF BIRTH
(YYYYMMDD)

8. E-MAIL ADDRESS

7. TELEPHONE NUMBER (Include Area Code)
a. HOME
b. CELLULAR

9. RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code) 10. MAILING ADDRESS (If correspondence, including premium notices,
are to be mailed to an address other than the residence address)
X

D R A F T

X
X

11. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime plan or USFHP.) (Honoring your preference depends
upon availability and local Military Treatment Facility (MTF) policy. Contact your TRICARE Service Center, preferred MTF, or US Family Health
Plan Member Services for availability of PCMs.) (Complete all that apply.)
a. PCM FULL NAME,
MTF/CLINIC
ADDRESS
(If known)

1st CHOICE
MTF
Other
2nd CHOICE
MTF
Other

b. PCM SPECIALTY

No Preference

c. PREFERRED PCM GENDER

DD FORM X605, 20110310 DRAFT

Family/General Practice

Flight Medicine

Internal Medicine

No Preference

Male

Female
Adobe Professional 8.0

UNIFORMED SERVICES SPONSOR THROUGH WHOM APPLICANT QUALIFIES FOR COVERAGE
12. NAME (Last, First, Middle Initial)
13. SOCIAL SECURITY NUMBER (SSN)
14. DATE OF BIRTH
OR DoD BENEFITS NUMBER (If known)
(YYYYMMDD)
15. STATUS (X one)
Active Duty

Retired

Selected Reserve

Retired Reserve

Transitional Assistance Management Program

16. PREMIUM PAYMENT METHOD (Three months of initial premiums are required. See below for currently monthly premiums.) (X as applicable.)
Check/Money Order/Cashiers Check for initial payments only
3 MONTHS OF PREMIUMS NOW DUE:
(Enclose applicable premium payable to contractor listed below)
$
Visa/Mastercard initial payments only (NOT monthly payments)
Visa/Mastercard initial and automatic monthly payments
CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF
CARDHOLDER:

CARDHOLDER
SIGNATURE:

Electronic Funds Transfer - automatic monthly payments

Checking (attach voided check)

NAME AND ADDRESS OF
FINANCIAL INSTITUTION:
NAME ON
ACCOUNT:

TELEPHONE NUMBER OF
FINANCIAL INSTITUTION:

ACCOUNT NUMBER:

BANK OR ABA ROUTING NUMBER:

Savings

17. APPLICANT'S SIGNATURE AND DATE

By signing this form, I understand that it is my responsibility to comply with all TRICARE Young Adult requirements. I certify the
information provided on this form is true, accurate, and complete.
Federal funds are involved in this program and any false claims, statements, comments, or concealment of a material fact may be
subject to fine and imprisonment under applicable Federal and State laws.
I certify that I am not eligible to enroll in an employer-sponsored health plan offered through my employer as defined by Section 5000A(f)(2) of
the IRS Code of 1986. If I should become eligible to enroll in an employer-sponsored health plan offered through my employer as defined by
Section 5000A(f)(2) of the IRS Code of 1986, I will submit a request to terminate my TRICARE Young Adult coverage.
I certify that I am not married.

D R A F T

I certify that I understand that a noonsufficient funds fee will be charged whenever a financial institution rejects a premium payment transaction
due to insufficient funds.
Complete as necessary if purchasing Prime coverage. If I am outside the service area, I understand and accept that my travel time to the
network of primary care delivery sites may exceed 30 minutes from my home to the delivery site and my travel time for specialty care may
exceed 1 hour.
Complete as desired. If available, I elect to receive TRICARE Young Adult information, premium statements, and benefit change
correspondence via e-mail or by links to websites.
a. APPLICANT SIGNATURE

b. DATE SIGNED (YYYYMMDD)

TRICARE YOUNG ADULT PROGRAM
Submission of this form does not automatically result in a requested action. You must meet all qualifications for coverage and pay
appropriate premiums. Policy premiums are updated annually.
The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program. Coverage is extended
from age 21 (age 23 if enrolled in a full-time course of study at an institution of higher learning approved by the Secretary of Defense)
up to age 26 for unmarried dependents that are not eligible for medical coverage from an eligible employer-sponsored health plan as a
result of their employment.
Qualified dependents can purchase either the TRICARE Prime or Standard/Extra benefits based upon meeting specific program
requirements and the availability of a desired plan in their geographic location.
For information on eligibility, enrollment, coverage, costs, claims submission, and additional program information, go to:
www.tricare.mil or contact the servicing contractor listed below:

DD FORM X605 (BACK), 20110310 DRAFT

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