Form DD 2947 DD 2947 TRICARE YOUNG ADULT APPLICATION

OMB No. 0720-0049
OMB approval expires

TRICARE YOUNG ADULT APPLICATION

The public reporting burden for this collection of information is estimated to average 15 minutes 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 (0720-0049). 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 DESIRED SERVICING CONTRACTOR SHOWN ON THE LAST PAGE.

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.

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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.
2. REQUESTED EFFECTIVE/TERMINATION/
TRANSFER/PCM CHANGE DATE (YYYYMMDD)

1. REQUESTED ACTION (X one)
Start coverage (complete Items 1 - 10, 11 as needed, 12 - 17)
Terminate TYA coverage (complete items 1 - 10, 12 - 14, and 17):
Have employer-sponsored healthcare

Marriage

Voluntary

Transfer coverage to another TYA Plan (complete items 1 - 10, 11 as needed,12 - 14, and 16 - 17).
If necessary, recurring monthly premiums will be adjusted accordingly.
Request change of Primary Care Manager (PCM) (complete items 1 - 2, 4 - 14,and 17).
3. TRICARE COVERAGE DESIRED (X one) (See Instructions for additional information about what TYA coverage you may be eligible to purchase
based on your Uniformed Services sponsor status and your geographical location. Not all applicants will qualify for TRICARE Prime or Uniformed
Services Familly Health Plan coverage.)
TRICARE Prime

Uniformed Services Family Health Plan

TRICARE Standard

TYA APPLICANT INFORMATION
(Enter information about the Young Adult Dependent)
4. NAME (Last, First, Middle Initial)

5. SOCIAL SECURITY NUMBER (SSN)
OR DoD BENEFITS NUMBER (If known)

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)

11. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime plan or USFHP, or requesting a PCM change.)
(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.)
a. FULL NAME OF PCM
1st CHOICE
OR MTF PREFERENCE

2nd CHOICE

b. PCM SPECIALTY

No Preference

c. PREFERRED PCM GENDER

DD FORM 2947, 20111006 DRAFT

Family/General Practice

Flight Medicine

Internal Medicine

No Preference

Male

Female

PREVIOUS EDITION IS OBSOLETE.

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UNIFORMED SERVICES SPONSOR THROUGH WHOM APPLICANT QUALIFIES FOR COVERAGE
(Enter information about the Uniformed Services Sponsor of the Young Adult Dependent)
12. NAME (Last, First, Middle Initial)

13. SOCIAL SECURITY NUMBER (SSN)
OR DoD BENEFITS NUMBER (If known)

14. DATE OF BIRTH
(YYYYMMDD)

15. PREMIUM PAYMENT METHOD (X and complete as applicable.) (See last page for monthly premium amounts.)

Failure to complete this section when requesting new and/or recurreng TYA coverage will result in your application being returned
without action.
a. Initial Premiums (Three months of initial premiums are required.)
Check/Money Order/Cashier's Check
(Enclose applicable premium payable to contractor on last page)

PAYMENT AMOUNT: $

Visa/MasterCard Credit or Debit Card:
CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF
CARDHOLDER:

CARDHOLDER
SIGNATURE:

CARDHOLDER
BILLING ADDRESS:

b. Recurring Automated Monthly Premiums (Recurring monthly premiums must be paid via a Recurring Credit Charge on a Visa/MasterCard
credit or debit card or an Electronic Funds Transfer from a checking or savings account; either option is initiated and maintained by your servicing
contractor. Failure to ensure premiums can be paid monthly via automated means will result in termination of TYA coverage.)
Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.

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Other Visa/MasterCard Credit or Debit Card:
CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF
CARDHOLDER:

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CARDHOLDER
SIGNATURE:

CARDHOLDER
BILLING ADDRESS:

Electronic Funds Transfer (EFT).

From:

Checking (Optional - attach voided check)

or

Savings

NAME AND ADDRESS OF
FINANCIAL INSTITUTION
NAME ON ACCOUNT
ACCOUNT NUMBER

TELEPHONE NUMBER OF
FINANCIAL INSTITUTION
BANK OR ABA ROUTING
NUMBER (see example below)

ACCOUNT HOLDER
SIGNATURE

DD FORM 2947, 20111006 DRAFT

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16. ATTESTATIONS BY THE YOUNG ADULT DEPENDENT APPLICANT
By signing this form, I understand that it is my responsibility to comply with all TRICARE Young Adult Program 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 understand that a nonsufficient funds fee may be charged whenever a financial institution rejects a premium payment transaction due to insufficient
funds.

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I understand that recurring monthly premiums must be paid via Recurring Credit Charge on a Visa/MasterCard credit or debit card or an Electronic Funds
Transfer from a checking or savings account. Failure to ensure premiums can be paid monthly via automated means will result in termination of my TYA
coverage.
I understand that recurring monthly premiums may be adjusted as necessary based on a change in the TYA coverage desired or due to changes in
monthly premium amounts required by law.
If I should become eligible to enroll in an employer-sponsored health plan offered by 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 Program coverage.
I understand that if I selected a Primary Care Manager (PCM) by name, team or location (MTF or civilian), the TRICARE Program will enroll me with that
PCM if capacity exists. If my selected PCM is greater than a 30 minute drive-time from my residence, I understand that I must waive this primary care access
standard. If I reside outside the Prime Service Area, I understand that I must also waive the specialty care access standard of one hour drive-time from my
PCM's location. This application constitutes my request for and my agreement to waive both the primary care access standard and the specialty care access
standard as applicable.
COMPLETION IS MANDATORY - X YES OR NO FOR EACH STATEMENT
Yes

No

I am 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.

Yes

No

I am married.
COMPLETION IS OPTIONAL - X YES OR NO

Yes

No

If available, I elect to receive TRICARE Young Adult Program information and correspondence via electronic media (e-mail, links
to websites, etc.).

17. SIGNATURE OF YOUNG ADULT DEPENDENT APPLICANT
a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

TRICARE YOUNG ADULT PROGRAM
Submission of this form does not automatically result in a requested action. Applicants 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 (including Uniformed Services Family Health Plan) or Standard/Extra coverage based
upon the uniformed service sponsor status, availability of a desired plan in a geographic location, and meeting specific program requirements of a desired
plan. General eligibility requirements are shown in the table below.
DEPENDENT ELIGIBILITY TO PURCHASE TRICARE YOUNG ADULT COVERAGE
INSIDE THE CONTINENTAL UNITED STATES
Sponsor Status

TRICARE Prime

TRICARE
Standard/Extra

OUTSIDE THE CONTINENTAL UNITED STATES

Uniformed Services
Family Health Plan

TRICARE Prime

TRICARE
Standard/Extra

Active Duty

Yes

Yes

Yes

Yes

Yes

Retired

Yes

Yes

Yes

No

Yes

Selected Reserve

No

Yes

No

No

Yes

Retired Reserve

No

Yes

No

No

Yes

For specific information on eligibility, enrollment, coverage, costs, claims submission, and additional program information, go to: www.tricare.mil or
contact a servicing contractor listed below:
(Enter servicing contractor contact information. Include current TYA premiums.)

DD FORM 2947, 20111006 DRAFT

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