2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Car

TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CARE MANAGER (PCM) CHANGE FORM	OMB No. XXXX-XXXX OMB approval expires XXXXXXXX
The public reporting burden for this collection of information, 0720-0008, 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, at [email protected]. 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. RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS BELOW.
PRIVACY ACT STATEMENT AUTHORITY: 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17; 32 CFR 199.17; and E.O. 9397 (SSN), as amended. PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to enroll, disenroll, or change their provider in TRICARE Prime, TRICARE Prime Remote, or the Uniformed Services Family Health Plan, as requested by the individual. ROUTINE USE(S): Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, as implemented by DoD 6025.18-R, the DoD Health Information Privacy Regulation. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the DoD "Blanket Routine Uses" under 5 U.S.C. 552a(b)(3) apply to this collection. A complete listing of the routine uses permitted under 5 U.S.C. 552a(b)(3) is published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Collected information may be shared with the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and other Federal, State, local, or foreign government agencies, 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, your failure to provide all the requested information may result in the denial of the request to enroll in, transfer, or terminate your TRICARE Prime health plan coverage.
APPLICATION OPTIONS
ONLINE: You may request to enroll, disenroll or change your primary care manager (PCM) by logging into the Beneficiary Web Enrollment website at https://www.dmdc.osd.mil/appj/bwe/. TELEPHONE: You may enroll, disenroll, or change your PCM by calling your Regional Contractor or US Family Health Plan (USFHP) at the toll-free numbers on this page. ENROLLMENT FORM: You may also enroll, disenroll, or change your PCM by completing and submitting the form to your Regional Contractor or USFHP at the address or fax number below. NOTES: You will be notified of your enrollment or PCM change via email or postcard. You can then log into milConnect at: https://www.dmdc.osd.mil/milconnect/ to view specific information. For additional information on TRICARE, visit the TRICARE website at www.tricare.mil or the Regional Contractor's website at: www.tricare-west.com
REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS: Region: WEST REGION Address: Health Net Federal Services, PO Box 8458, Virginia Beach, VA 23450-8458 Toll-Free Number: 1-844-866-WEST (1-844-866-9378) Fax Number: 1-844-388-8282
UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP): Address: (1) USFHP at CHRISTUS Health, PO Box 169001, Irving TX 75016 (2) Pacific Medical Centers, PO Box 84985, Seattle WA 98124 Toll-Free Number: (1) 1-800-678-7347 (2) 1-888-958-7347 option 1 Fax Number: (1) 1-210-766-8854 (2) 1-206-326-2458

Adobe Professional X

_{DD FORM 2876-2, JUL 2016} PREVIOUS EDITION IS OBSOLETE. ^{Page 1 of 5 Pages}

SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED: TRICARE Prime: Active duty service members have to enroll in TRICARE Prime. (Enrollment is not automatic.) TRICARE Prime Remote: If eligible, you may be enrolled in TRICARE Prime Remote or TRICARE Prime Remote for Active Duty Family Members. TRICARE Overseas Program Prime: Family members must be command sponsored and meet specific enrollment criteria of the overseas area. If eligible, you may be enrolled in TRICARE Overseas Program Prime Remote. Retirees are not eligible for TRICARE Overseas Program Prime. Uniformed Services Family Health Plan (USFHP): Available in six locations. Submit the completed Enrollment Application to the USFHP address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the TRICARE website at www.tricare.mil/usfhp.
SECTION I - SPONSOR INFORMATION
1. SPONSOR'S NAME (Last, First, Middle Initial) (Must match DEERS)							2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN) (XXX-XX-XXXX) or DoD BENEFITS NUMBER (DBN) (XXXXXXXXX-XX)
3. SPONSOR IS: (X one)	Active Duty		R	etired		Deceased (Go to Section II.)		Unremarried Former Spouse
SPONSOR'S TELEPHONE NUMBER (Include Area Code) WORK: c. CELL: HOME:					5. SPONSOR'S E-MAIL ADDRESS				6. SPONSOR'S DATE OF BIRTH (YYYYMMDD)
7. SPONSOR'S RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code, Country) New
8. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas) Same as residence New
9. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT						c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS
b. UNIT IDENTIFICATION CODE (UIC) (If known)
10. SPONSOR'S REQUESTED ACTION (X one) None (go to Section II) Enroll Transfer Enrollment PCM Change Disenroll (Non-AD only) Effective Date Requested:
11. SPONSOR'S PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and your uniformed service guidelines. Review PCM options online or call your Regional Contractor, preferred MTF, or USFHP member services (non-active duty only) for availability of PCMs.)
a. 1st CHOICE MTF PRP (ADSM) Civilian	FULL NAME or MTF/CLINIC
b. 2nd CHOICE MTF Civilian	FULL NAME or MTF/CLINIC
c. PCM SPECIALTY No Preference Family/General Practice Internal Medicine Flight Medicine
d. PREFERRED PCM GENDER No Preference Male Female

SPONSOR'S SSN/DBN:
SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE (Use additional copies of this page as necessary)
12.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)							b. DATE OF BIRTH (YYYYMMDD)
c. REQUESTED ACTION:		Enroll		Transfer Enrollment PCM Change Disenroll Effective Date Requested:
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
	Same as Sponsor	New
e. TELEPHONE NUMBER (Include Area Code) (1) WORK: (2) HOME:				(3) CELL:		f. E-MAIL ADDRESS
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines. Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
(1) 1st CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
(2) 2nd CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
h. PCM SPECIALTY		No Preference		Family/General Practice Internal Medicine Pediatrics Flight Medicine
i. PREFERRED PCM GENDER				No Preference Male Female
13.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)							b. DATE OF BIRTH (YYYYMMDD)
c. REQUESTED ACTION:		Enroll		Transfer Enrollment PCM Change Disenroll Effective Date Requested:
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
	Same as Sponsor		New
e. TELEPHONE NUMBER (Include Area Code) (1) WORK: (2) HOME:				(3) CELL:		f. E-MAIL ADDRESS
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines. Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
(1) 1st CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
(2) 2nd CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
h. PCM SPECIALTY		No Preference		Family/General Practice Internal Medicine Pediatrics Flight Medicine
i. PREFERRED PCM GENDER				No Preference Male Female
14.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)							b. DATE OF BIRTH (YYYYMMDD)
c. REQUESTED ACTION:		Enroll		Transfer Enrollment PCM Change Disenroll Effective Date Requested:
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
	Same as Sponsor		New
e. TELEPHONE NUMBER (Include Area Code) (1) WORK: (2) HOME:				(3) CELL:		f. E-MAIL ADDRESS
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines. Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
(1) 1st CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
(2) 2nd CHOICE MTF		Civilian		Same as Sponsor	FULL NAME or MTF/CLINIC
h. PCM SPECIALTY		No Preference		Family/General Practice Internal Medicine Pediatrics Flight Medicine
i. PREFERRED PCM GENDER				No Preference Male Female

SPONSOR'S SSN/DBN:
SECTION III - REASON FOR DISENROLLMENT OR PCM CHANGE (Complete if disenrolling or making a PCM change)
Name of Family Member:	Relocation Dissatisfied PCS Other:
Name of Family Member:	Relocation Dissatisfied PCS Other:
Name of Family Member:	Relocation Dissatisfied PCS Other:
Name of Family Member:	Relocation Dissatisfied PCS Other:
SECTION IV - OTHER HEALTH INSURANCE
PLEASE IDENTIFY IF ANYONE IS CURRENTLY COVERED BY OTHER HEALTH INSURANCE. TRICARE Supplement (no other information is needed) Medical Insurance: Person(s) Covered: Policy Holder Name: Carrier Name: Policy Number: Policy Effective Date: Dental Insurance: Person(s) Covered: Policy Holder Name: Carrier Name: Policy Number: Policy Effective Date: Vision Insurance: Person(s) Covered: Policy Holder Name: Carrier Name: Policy Number: Policy Effective Date: Prescription Insurance: Person(s) Covered: Policy Holder Name: Carrier Name: Policy Number: Policy Effective Date:
SECTION V - ACCESS WAIVER AND SIGNATURE (REQUIRED)
(X if waiving drive time) If my selected or assigned Primary Care Manager (PCM) is greater than a 30 minute drive-time from my residence, or if I reside outside the Prime Service Area, I hereby waive the drive time standards of thirty minutes for primary care and one hour for specialty care I understand if I selected a PCM by name, team, or location (MTF or civilian), TRICARE will enroll me with that PCM subject to PCM availability and uniformed services policy. I understand that it is my responsibility to comply with all TRICARE Prime, TRICARE Prime Remote, TRICARE Overseas Program Prime, and/or USFHP policies and procedures. By signing this form, I certify the information provided 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/or imprisonment under applicable Federal law.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL GUARDIAN OF BENEFICIARY		2. RELATIONSHIP TO SPONSOR	3. DATE SIGNED (YYYYMMDD)
ENROLLMENT NOTE: Prime enrollment start dates are based primarily on the 20th of the month rule (applications received on/before the 20th of the month are effective the first calendar day of the next month). You should confirm enrollment and PCM assignment before obtaining routine medical care. (Note: This does not apply to TRICARE Overseas Prime or to active duty service members.) DISENROLLMENT NOTE: In some cases, you may not be able to re-enroll in TRICARE Prime for a 12-month period from the date of the disenrollment. This one year period does not apply to any family member whose sponsor is in grade E-1 to E-4. PAYMENT OPTIONS: See Section VI on next page.

SPONSOR'S SSN/DBN:

SECTION VI - PAYMENT OF TRICARE PRIME ENROLLMENT FEES

NOTE: This section is only for retirees, retiree family members, survivors and eligible former spouses. Retired beneficiaries and retiree family members under age 65 who are entitled to Medicare Part A must be enrolled in Medicare Part B to be eligible for enrollment in TRICARE Prime. TRICARE Prime enrollment fees are waived for individuals enrolled in Medicare Part A and Part B, as reflected in DEERS. PAYMENT OPTIONS: See Sections A, B, and C below for payment options. Note 1, Monthly Payment: Monthly payments must be recurring payments. You will not receive a monthly bill. If you select the monthly payment plan, you must make an initial three month payment by check (cashier's or personal check), credit/debit card, or money order at the time of application. Make checks payable to: Health Net Federal Services, LLC Note 2, Quarterly and Annual Payments: You will be billed on a quarterly or annual basis for credit card payments. (Your Contractor may offer recurring quarterly and/or annual payments.) Note 3, Personal Check: Payment by check (money order, cashier's or personal) is limited to the initial three month payment only. Checks received for ongoing payment will not be accepted. Note 4, Electronic Funds Transfer: EFT is for monthly or quarterly payments only. The initial payment cannot be made via EFT.

PAYMENT FEE, PLAN AND METHOD OPTIONS (Some options are location specific)

MONTHLY

Allotment From Retired Pay

Electronic Funds Transfer

VISA or MasterCard

INITIAL 3-MONTH PAYMENT:

Check

Money Order

Credit/Debit Card (Section C below)

QUARTERLY VISA or MasterCard

ANNUAL

VISA or MasterCard

I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay. NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The Uniformed Service member must sign below. Your Regional Contractor will charge the correct fee amount each month based on your enrollment, individual or family. (The current rates are at www.tricare.mil/costs)

B - ELECTRONIC FUNDS TRANSFER

ELECTRONIC FUNDS TRANSFER FOR AUTOMATIC PAYMENTS Checking (attach voided check) Savings Name and Address of Financial Institution Name on Account Telephone Number of Financial Institution Account Number ABA Routing Number NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family. (The current rates are at www.tricare.mil/costs)

C - CREDIT/DEBIT CARD

INITIAL 3-MONTH PAYMENT VISA/MASTERCARD MONTHLY RECURRING PAYMENTS: CREDIT/DEBIT CARD: Num: ber Exp. Date (MM/YYYY) Security Code (3-digit number on reverse side of card) Name of Cardholder NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family. (The current rates are at www.tricare.mil/costs)

SIGNATURE

My signature authorizes the Regional Contractor to START, CHANGE, or STOP my automated payments as indicated above. Fee amounts, as determined by TRICARE and subject to change each fiscal year, will be withdrawn between the first and the fifth business day based on the payment option selected. This authorization will remain in force unless cancelled by me, my Regional Contractor or my financial institution. I understand a $20.00 administrative fee may be assessed for any payments returned due to insufficient or unavailable funds.

SIGNATURE OF SPONSOR, SPOUSE OR OTHER LEGAL GUARDIAN OF BENEFICIARY

DATE