DD Form 2854 TRICARE Plus Disenrollment Form

TRICARE PLUS DISENROLLMENT REQUEST

OMB No. 0720-0028
OMB approval expires

(Read Agency Disclosure Notice, Privacy Act Statement,
and Instructions before completing form.)
AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 7 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, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0720-0028). 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
military treatment facility where you are currently enrolled.

N E E D S

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PRIVACY ACT STATEMENT

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AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR Part 199, Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS); and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): This form collects the information necessary to process your request to disenroll from TRICARE Plus.
ROUTINE USE(S): Your records may be disclosed to Federal agencies, and state, local and territorial governments, in order to
collect debts and overpayments, to determine whether beneficiaries are eligible for, or enrolled in, other government or private
health insurance plans, and to stop fraud, waste, and abuse. Use and disclosure of your records outside of DoD may occur in
accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD Blanket Routine Uses
published at: http://dplco.defense.gov/privacy/SORNs/blanket_routine_uses.html.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy
Rule (45 CFR Parts160 and 164), as implemented within DoD by DoD 6025.18-R. Permitted uses and disclosures of PHI include,
but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in the denial of your request to
disenroll from TRICARE Plus.

INSTRUCTIONS
1. Print all information in ink. Make sure the information is complete and accurate.
2. Ensure personal information matches information in the Defense Enrollment Eligibility Reporting System (DEERS).
To check your DEERS information, call the Defense Manpower Data Center Support Office at 1-800-538-9552 or refer
to your name as printed on your ID card. The mailing address and telephone numbers you include on this form will
update DEERS.
3. Sign and date the application (Section III).
4. Please keep a copy of the completed application for your records.
5. Submit your completed disenrollment application to the MTF where you are currently enrolled.
6. For information on TRICARE, visit the TMA Website at www.tricare.osd.mil
.
DD FORM 2854 INSTRUCTIONS, 20130916 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional X

TRICARE PLUS DISENROLLMENT REQUEST
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)
SECTION I - SPONSOR INFORMATION (Must be completed on all applications)
1. Sponsor Social Security Number
2. Sponsor Name (Last, First, Middle Initial)
(SSN) or DoD Benefits Number (DBN)

3. Date of Birth
(YYYYMMDD)

SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT
4. a. Name (Last, First, Middle Initial)

b. Date of Birth (YYYYMMDD)

c. Reason for Disenrollment (X one)
Other (Explain)

Moved
Loss of TRICARE Eligibility
Request for Voluntary Disenrollment
Death
d. Requested Disenrollment Date
(YYYYMMDD)

e. Telephone Number (Include area code)
(1) Home

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f. E-mail Address

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5. a. Name (Last, First, Middle Initial)

(2) Work

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X to receive TRICARE e-mails
b. Date of Birth (YYYYMMDD)

c. Reason for Disenrollment (X one)
Other (Explain)

Moved
Loss of TRICARE Eligibility
Request for Voluntary Disenrollment
Death
d. Requested Disenrollment Date
(YYYYMMDD)

e. Telephone Number (Include area code)
(1) Home

(2) Work

SECTION III - SIGNATURE
6. By signing this form, I certify that the information on this form is true, accurate, and complete.
a. Signature

b. Date Signed (YYYYMMDD)

Return ORIGINAL completed form to the Military Treatment Facility where you are currently enrolled.
Keep a copy for your records.
DD FORM 2854, 20130916 DRAFT