DD-3043-3 TRICARE Select Enrollment, Disenrollment, and Change For

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TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FORM

OMB No. 0720-0061
OMB approval expires:
XXXXXXXX

The public reporting burden for this collection of information, 0720-0061, 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 the burden estimate or burden reduction suggestions 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 REGIONAL CONTRACTOR ADDRESS LISTED BELOW:
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1075 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 enrollment region for TRICARE Select
coverage as requested by the individual.
ROUTINE USE(S): 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: EDHA 07, “Military Health Information System” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/
Privacy/SORNs/DHA/EDHA-07.pdf
DISCLOSURE: Voluntary; however, your failure to provide all the requested information may result in the denial of the request to enroll, disenroll, or change the
enrollment for your TRICARE Select health plan coverage.
TRICARE SELECT
TRICARE Select is a preferred provider organization (PPO) plan, offering access to network and non-network providers. Your out-of-pocket expenses are less if
you use network providers. Referrals for care are not required.

NEEDS DD67

If eligible for TRICARE, you must enroll in either TRICARE Select (or Prime) or you will be considered as having declined TRICARE coverage. Declining
coverage means TRICARE will not process your claims from civilian providers and you will only be eligible for space-available care at a military hospital or clinic.
If you choose not to enroll, you can enroll during the annual open enrollment period with coverage starting on the first of the following year or following a
qualifying life event (see www.tricare.mil/LifeEvents for details). You have 90 days from the life event to enroll and your coverage will start on the date of the
event (e.g., marriage, birth).
The Department of Defense establishes enrollment fees annually. Active duty family members, certain survivors of active duty deceased service members, and
medically retired uniformed service members and their dependents do not pay an enrollment fee. All others must pay the appropriate enrollment fee. If you do
not pay your TRICARE Select enrollment fee, you will lose your TRICARE coverage and only be eligible for space-available care at a military hospital or clinic.
HOW TO ENROLL, DISENROLL OR MAKE CHANGES
You have 3 ways to enroll, disenroll or change your enrollment:
(1) ONLINE:
Log into the Beneficiary Web Enrollment (BWE) website (www.tricare.mil/BWE). You need a Common Access Card (CAC), DS Logon or a DFAS account to
log in.
(2) TELEPHONE:
Call your regional contractor at the toll-free number below.
(3) Mail or FAX:
Complete and mail or FAX this form to your Regional Contractor at the address or FAX number below.
NOTES:
You will be notified of your enrollment or change in writing. You can view your enrollment status at milConnect ( www.tricare.mil/milconnect).
To learn more about TRICARE, go to www.tricare.mil or your Regional Contractor's website below.
REGIONAL CONTRACTOR
Contractor:
Address:

Toll-Free Number:

Fax Number:

Website:

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Controlled by: TRICARE Health Plan Division
Category: INFOSEC/OPSEC/PII
Distribution/DISTRO: FEDCON
POC: 571-232-1551

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SPONSOR'S SSN / DBN

SECTION I - SPONSOR INFORMATION
1. SPONSOR'S NAME (Last, First, Middle Initial)

3. SPONSOR IS: (X one)

(Must match DEERS)

Active Duty

Retired

4. SPONSOR'S TELEPHONE NUMBER (Include Area Code)
a. HOME:

2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN) (XXX-XX-XXXX)
or DoD BENEFITS NUMBER (DBN) (XXXXXXXXX-XX)

Unremarried Former Spouse

Deceased (Go to Section II.)
6. SPONSOR'S
DATE OF BIRTH (YYYYMMDD)

5. SPONSOR'S E-MAIL ADDRESS

c. CELL:

b. WORK:
New

7. SPONSOR'S RESIDENCE ADDRESS
a. STREET

b. CITY

c. STATE

d. ZIP CODE

e. COUNTRY

8. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)
a. STREET
c. STATE

Same as residence

New

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b. CITY

d. ZIP CODE

e. COUNTRY

9. REQUESTED ACTION FOR ELIGIBLE BENEFICIARIES (X one)

None (go to Section II)

Enroll

Disenroll

Decline Coverage

Effective Date Requested:

Change Enrollment Region

SECTION II - ENROLLING FAMILY MEMBER INFORMATION (Use additional copies of this page as necessary)
b. DATE OF BIRTH (YYYYMMDD)

10. a. FAMILY MEMBER NAME (Last, First, Middle Initial)

(Must match DEERS)

c. REQUESTED ACTION

Change Enrollment Region

Enroll

Disenroll

d. ADDRESS (Provide address, if different from Sponsor)

Same as Sponsor

Decline Coverage

Effective Date Requested:

New

(1) HOME:
(2) MAILING:
e. TELEPHONE NUMBER (Include Area Code)
(1) HOME:

f. E-MAIL ADDRESS

(2) WORK:

(3) CELL:
b. DATE OF BIRTH (YYYYMMDD)

11. a. FAMILY MEMBER NAME (Last, First, Middle Initial)

(Must match DEERS)

c. REQUESTED ACTION

Change Enrollment Region

Enroll

Disenroll

d. ADDRESS (Provide address, if different from Sponsor)

Same as Sponsor

Decline Coverage

Effective Date Requested:

New

(1) HOME:
(2) MAILING:
e. TELEPHONE NUMBER (Include Area Code)
(1) HOME:

f. E-MAIL ADDRESS

(2) WORK:

(3) CELL:
b. DATE OF BIRTH (YYYYMMDD)

12. a. FAMILY MEMBER NAME (Last, First, Middle Initial)

(Must match DEERS)

c. REQUESTED ACTION

Change Enrollment Region

Enroll

Disenroll

d. ADDRESS (Provide address, if different from Sponsor)

Same as Sponsor

Decline Coverage

Effective Date Requested:

New

(1) HOME:
(2) MAILING:
e. TELEPHONE NUMBER (Include Area Code)
(1) HOME:

(2) WORK:

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f. E-MAIL ADDRESS
(3) CELL:

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SPONSOR'S SSN / DBN

SECTION III - REASON FOR DISENROLLING OR DECLINING COVERAGE
1. NAME OF FAMILY MEMBER:

Gained Other Health Insurance

Chose Other TRICARE Plan

Other
2. NAME OF FAMILY MEMBER:

Gained Other Health Insurance

Chose Other TRICARE Plan

Other
3. NAME OF FAMILY MEMBER:

Gained Other Health Insurance

Chose Other TRICARE Plan

Other
4. NAME OF FAMILY MEMBER:

Gained Other Health Insurance

Chose Other TRICARE Plan

Other

SECTION IV - OTHER HEALTH INSURANCE
PLEASE IDENTIFY IF ANYONE IS CURRENTLY COVERED BY OTHER HEALTH INSURANCE.

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1. TRICARE Supplement (no other information is needed)
2. Medical Insurance:

b. Policy Holder Name:

3. Dental Insurance:
b. Policy Holder Name:

4. Vision Insurance:
b. Policy Holder Name:

5. Prescription Insurance:
b. Policy Holder Name:

a. Person(s) Covered:
c. Carrier Name:

d. Policy Number:

e. Policy Effective Date

d. Policy Number:

e. Policy Effective Date

d. Policy Number:

e. Policy Effective Date

d. Policy Number:

e. Policy Effective Date

a. Person(s) Covered:
c. Carrier Name:

a. Person(s) Covered:
c. Carrier Name:

a. Person(s) Covered:
c. Carrier Name:

SECTION V - SIGNATURE (REQUIRED)
I understand it is my responsibility to comply with all TRICARE Select policies and procedures. By signing this form, I certify the information provided is
true and accurate. 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: Your regional contractor will process your enrollment, disenrollment or change request to be effective on the date
requested or the date of event (e.g., initial eligibility, marriage, birth) as appropriate. If your regional contractor receives your enrollment
request within 90-days of loss of other TRICARE or healthcare coverage, your TRICARE Select coverage starts on the day after the loss of
your other coverage. You should confirm the enrollment or change before obtaining care by calling your Regional Contractor or by viewing
your enrollment on milConnect ( www.tricare.mil/milconnect).
DISENROLLMENT NOTE: If you voluntarily disenroll or do not pay your enrollment fee, you will only have space available care at a
military hospital or clinic. You may re-enroll during the next open enrollment period or within 90-days of a qualifying life event (see
www.tricare.mil/LifeEvents for details). You have 90-days from the life event to enroll and your coverage will start on the date of the
event (e.g., marriage, birth).
PAYMENT OPTIONS: See Section VI on next page.

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SPONSOR'S SSN / DBN

SECTION VI - PAYMENT OF TRICARE SELECT ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, certain survivors and eligible former spouses.
If you are entitled to Medicare Part A, you must have Medicare Part B to remain TRICARE-eligible. Retired beneficiaries with any Medicare
coverage are not eligible to enroll in TRICARE Select. If you are on Medicare and have any questions regarding your TRICARE eligibility, call
your Regional Contractor at the toll-free number on page 1.
ACKNOWLEDGMENT REQUIRED
Failure to pay monthly premiums by automated means will result in termination of TRICARE Select coverage and will result in direct care only
coverage on a space available basis.

PAYMENT PLAN OPTION:
Monthly Payment Plan: Monthly payments must be recurring electronic payments. You can pay with an allotment from your retired pay,
Electronic Funds Transfer (ETF), or by credit/debit card. You will not receive a monthly bill. You must make an initial 3-month payment by
check (cashier's or personal check), money order, or credit/debit card at the time of enrollment.
Make your check payable to:
Quarterly Payment Plan: Quarterly payments must be made by credit/debit card or EFT. You will receive a bill each quarter.
Your regional contractor may give you the option for recurring quarterly payments.
Annual Payment Plan: Annual payments must be made by credit/debit card. You will receive a bill each year.
Your regional contractor may give you the option for recurring annual payments.
Note: Checks (cashier or personal) or money orders are only accepted for payment of initial enrollment fees.
Regional contractors will not accept checks or money orders for recurring payment of fees.

NEEDS DD67

PAYMENT OPTIONS MONTHLY

Allotment From Retired Pay

Electronic Funds Transfer

Credit/Debit Card

(Some options are
location specific)

Check

Money Order

Credit/Debit Card

INITIAL 3-MONTH PAYMENT

MONTHLY ALLOTMENT (where feasible, as mandated by law (NDAA for FY2020, Section 702))
Lack of feasibility includes instances where no (e.g., 100% disabled veterans, certain unremarried former spouses, survivors, etc.) or insufficient retired/retainer
pay is available to cover monthly enrollment fees. If allotment is not feasible, payments in the form of Electronic Funds Transfer (EFT) via recurring credit or
debit card are allowed.
I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay.
NOTE: Only retired Uniformed Services members and certain Survivors 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 http://www.tricare.mil/costs)

ELECTRONIC FUNDS TRANSFER
CHECKING (attach voided check)

SAVINGS

FINANCIAL INSTITUTION
a. Name:

b. Telephone Number:

c. Address:
d. Name on Account:
e. Account Number:

f. ABA Routing Number:

CREDIT/DEBIT CARD
INITIAL 3-MONTH PAYMENT

VISA/MASTERCARD MONTHLY RECURRING PAYMENTS (your Regional Contractor may offer other options):

a. Cardholder Name:
b. Credit/Debit Card Number:
d. Card Verification Code (CVC)
(3-digit number on reverse side of card)

c. Expiration Date (MM/YYYY)
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 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.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL GUARDIAN OF BENEFICIARY

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2. DATE (YYYYMMDD)

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