DD2853 TRICARE Plus Enrollment Application

TRICARE PLUS ENROLLMENT APPLICATION
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)

OMB No. 0720-0028
OMB approval expires
XXXXXXXX

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 the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected] (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 RETURN YOUR FORM TO THE Military Treatment Facility where you are requesting treatment.

PRIVACY ACT STATEMENT
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 enroll in TRICARE Plus.
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.
APPLICABLE SORN: DHA-07 Military Health Information System - http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORNArticle-View/Article/570672/edha-07/
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in the denial of your request to enroll in
TRICARE Plus.

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INSTRUCTIONS

This form is for eligible beneficiaries who want to enroll in TRICARE Plus. TRICARE Plus is an enrollment option for TRICARE
beneficiaries who want an affiliation with a primary care provider at a Military Treatment Facility (MTF) and are either ineligible
for TRICARE Prime or prefer a more limited relationship (primary care only). Enrollment in TRICARE Plus does not guarantee
access to services at the MTF, however, if you are accepted for enrollment you will be assigned to a primary care provider at
the MTF. The MTF will make every effort to provide complete and comprehensive primary care services within access
standards. Beneficiaries enrolled into TRICARE Plus agree to rely on their MTF primary care provider for all their nonemergency primary care.
GENERAL 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 you can log
into milConnect at: https://www.dmdc.osd.mil/milconnect/ to view specific information. 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 completed application to the MTF where you are requesting enrollment. Each MTF has local policies for
processing your application. For more information regarding enrollment to a specific MTF, contact the MTF directly.
6. For information on TRICARE Plus, contact any MTF or visit the Defense Health Agency (DHA) Website at www.tricare.mil.

DD FORM 2853, DRAFT 20210510

PREVIOUS EDITION IS OBSOLETE.

TRICARE PLUS ENROLLMENT APPLICATION
(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 (SSN) or
DoD Benefits Number (DBN)

2. Sponsor Name (Last, First, Middle Initial)

3. Date of Birth
(YYYYMMDD)

SECTION II - INDIVIDUAL ENROLLMENTS

4. Sponsor Requesting Enrollment
a. Mailing Address (Street/P.O. Box, Apartment Number, City,
State, ZIP Code)

c. Telephone Number
(Include area code)

(1) Home:

(2) Work:

b. Residence Address (If different from mailing address)

(3) Cell:

d. Sponsor's E-mail Address:

e. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice

(2) Second Choice

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X if under the care of this provider or MTF

X if under the care of this provider or MTF

For Government Use Only

5. Enrolling Family Members
b. Date of Birth (YYYYMMDD)

a. Name (Last, First, Middle Initial)
c. Mailing Address (Street/P.O. Box, Apartment Number,
City, State, ZIP Code)

X if same as sponsor

d. Residence Address (If different from mailing address)

X if same as sponsor
(1) Home:

(2) Work:

(3) Cell:

e. Telephone Number (Include area code):
f. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice

X if under the care of this provider or MTF

(2) Second Choice

X if under the care of this provider or MTF

For Government Use Only

DD FORM 2853, DRAFT 20210510

PREVIOUS EDITION IS OBSOLETE.

SECTION III - SIGNATURE
6.

I understand that TRICARE Plus:

(1) is a military treatment facility primary care enrollment program, not a comprehensive health plan;
(2) does not guarantee access to specialty care at the military treatment facility where the beneficiary is enrolled;
(3) enrollees may have out-of-pocket expenses for civilian health care;
(4) enrollment at this military treatment facility is not transferable to another military treatment facility; and
(5) by enrolling in TRICARE Plus I will be disenrolled from any other TRICARE enrollment program.
By signing this form, I certify that the information on this form is true, accurate and complete.

b. Date Signed (YYYYMMDD)

a. Signature

Return completed form to the Military Treatment Facility where you are requesting treatment.
Keep a copy for your records.

NEEDS DD67

DD FORM 2853, DRAFT 20210510

PREVIOUS EDITION IS OBSOLETE.