DD-2947-3 TRICARE Young Adult Application

OMB No. 0720-0049
OMB approval expires

TRICARE YOUNG ADULT APPLICATION

The public reporting burden for this collection of information, 0720-0049, 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 DESIRED SERVICING CONTRACTOR SHOWN BELOW.

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); DoD Instruction
1341.02, Defense Enrollment Eligibility Reporting System (DEERS) Program and Procedures; and E.O. 9397 (SSN), as amended.
PURPOSE: To collect the information necessary to process your request for coverage, to terminate coverage, or to change your provider.
ROUTINE USES: Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Collected
information may also be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or foreign government
agencies, or authorized private business entities. Additionally, information may be shared with the contractor responsible for management of the system. For a full listing of the
Routine Uses, please refer to the applicable SORN.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as
implemented within DoD. Permitted uses and discloses of PHI include, but are not limited to, treatment, payment, and healthcare operations. For a full listing of the applicable
Routine Uses for the system, refer to the applicable SORN.
APPLICABLE SORN: DMDC 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS) (July 27, 2016, 81 FR 49210) is the system of records notice (SORN)
applicable to DD 2947. The SORN can be found at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/
DISCLOSURE: Voluntary. However, failure to provide all requested information may result in a denial of your request to enroll in or change your TRICARE Young Adult health
plan coverage.
TRICARE YOUNG ADULT PROGRAM
The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program that allows former dependents to purchase TRICARE health care plan coverage if qualified.
Coverage is extended from age 21 (age 23 if previously enrolled in a full-time course of study at an institution of higher learning) until reaching age 26 for unmarried dependents that are not eligible for
medical coverage from employer-sponsored medical coverage as a result of their employment. General eligibility requirements are shown below.

TRICARE
Prime (1)

TRICARE
Prime
Remote (1)

TRICARE
Select

Uniformed
Services Family
Health Plan (1)

TRICARE
Overseas Prime (1)

TRICARE
Overseas Prime
Remote (1)

TRICARE
Overseas
Select

Active Duty

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Retired

Yes

No

Yes

Yes

No

No

Yes

Selected Reserve (2)

No

No

Yes

No

No

No

Yes

Retired Reserve (2)

No

No

Yes

No

No

No

Yes

Sponsor Status

(1) To purchase this coverage, it must be offered in your geographic area and you must meet all other eligibility criteria.
(2) If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be enrolled in TRICARE Reserve Select or TRICARE
Retired Reserve as applicable for you to be eligible to purchase TYA coverage. For specific information on eligibility, coverage, costs, claims submission, go to: www.tricare.mil/tya.

APPLICATION OPTIONS
ONLINE: You may electronically complete, submit and print a copy of your enrollment, disenrollment, transfer request to another TYA plan, or Primary Care Manager (PCM)
change form by logging into the Beneficiary Web Enrollment (BWE) website at https://www.tricare.mil/bwe/. The BWE website is not available to beneficiaries in overseas areas.
TELEPHONE: You may enroll, disenroll, transfer to another TYA plan, 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, transfer to another TYA plan, 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 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 or
USFHP website below.

For enrollment assistance, please call

International SOS Government Services

FAX: 1-215-354-5015

For additional information on TRICARE, visit the TRICARE website at www.tricare.mil, the Contractor's website at
or your local TRICARE Service Center (TSC).
www.tricare-overseas.com/contactus/

International SOS Government Services
TRICARE Young Adult (TYA) Enrollments/Disenrollment
PO Box 11689
Philadelphia, PA 19116
Note: Please leave voice line blank

Uniformed Services Family Health Plan (USFHP) (Include locations, addresses and telephone numbers.)
[Region]
[Region]
[Region]

[Region]

[US Family Health Plan]

[US Family Health Plan]

[US Family Health Plan]

[US Family Health Plan]

[Street Address]

[Street Address]

[Street Address]

[Street Address]

[City, State, 9-digit ZIP Code]

[City, State, 9-digit ZIP Code]

[City, State, 9-digit ZIP Code]

[City, State, 9-digit ZIP Code]

FAX: 1-207-828-7822

[1-800-XXX-XXXX]

[1-800-XXX-XXXX]

[1-800-XXX-XXXX]

DD FORM 2947-3, SEP 2016

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 4 Pages

Adobe Professional X

YOUNG ADULT’S SSN/DBN:

TRICARE Select: Includes dependents of sponsors enrolled in the TRICARE Reserve Select and TRICARE Retired Reserve health plans.
TRICARE Prime: Where available. Enrollment is not automatic. If eligible, active duty family members may be enrolled in TRICARE Prime
Remote for Active Duty Family Members (TPRADFM).
TRICARE Overseas Program Prime: Available in overseas locations for active duty family members only. Must be command sponsored
and meet specific overseas enrollment criteria. If eligible, you may be enrolled in TRICARE Overseas Prime Remote.
TRICARE Overseas Program Select: Available in overseas locations.
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 https://
www.tricare.mil/usfhp

(Last, First, Middle Initial) (Must match DEERS)

(XXX-XX-XXXX)
(XXXXXXXXX-XX)

(X one)

(Go to Section II.)

4.a. FAMILIY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)

b. DATE OF BIRTH (YYYYMMDD)

c. REQUESTED ACTION
d. RESIDENCE ADDRESS
(Provide address, with ZIP Code and Country)

e. MAILING ADDRESS
(Provide address, with ZIP Code and Country)

f. TELEPHONE NUMBER

(Include Area Code)

g. EMAIL ADDRESS

h. REASON FOR DISENROLLMENT OR PCM CHANGE

SECTION III - OTHER HEALTH INSURANCE
PLEASE IDENTIFY IF YOU ARE 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:

DD FORM 2947-3, SEP 2016

(X box to receive TRICARE e-mails)

YOUNG ADULT’S SSN/DBN:
SECTION IV - ACCESS WAIVER, ATTESTATIONS, AND SIGNATURE (REQUIRED)
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 or assigned PCM is greater than a 30 minute drive-time from my residence, or if
I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time
from my residence, and (2) this application constitutes my agreement to waive both the primary care access standard and specialty care
access standard as applicable.
I understand recurring monthly premium payments may be adjusted as necessary based on a desired change in TYA coverage or due to
changes in monthly premium amounts required by law.
I understand that it is my responsibility to comply with all TRICARE Young Adult 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.
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.

Yes

No

I am married.

SIGNATURE OF YOUNG ADULT DEPENDENT APPLICANT

DATE SIGNED (YYYYMMDD)

ENROLLMENT NOTE: Your regional or USFHP contractor will process your enrollment, disenrollment, or change request for coverage to
be effective on the date of receipt or up to 90 days in the future as requested by you. If the contractor receives your enrollment request
within 90 days of loss of other TRICARE or healthcare coverage, your TYA coverage starts on the day after the loss of your other
coverage. You should confirm enrollment (and PCM assignment for Prime plans) or PCM changes before obtaining care by calling your
Regional or USFHP contractor, or by viewing your enrollment on milConnect (www.tricare.mil/milconnect).
DISENROLLMENT NOTE: You may incur a 12 month lock-out from TYA coverage for failure to pay premiums or for voluntary termination
not associated with gaining employer-sponsored health plan coverage or regaining TRICARE coverage. You may not be allowed to
re-enroll in TYA coverage for 12 months from the date of the disenrollment.
PAYMENT OPTIONS: See Section V.
SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS
PREMIUM PAYMENT METHOD: (X and complete as applicable.) (See www.tricare.mil/costs for current rates.)
Failure to complete both parts a. and b. of this section when requesting new and/or recurring TYA coverage will result in your application being returned
without action.
a. INITIAL PREMIUMS: To purchase TYA coverage, young adult dependents or other responsible individual should submit an application

request along with an initial 2-month payment by check (cashier's or personal check), money order, or credit/debit card at the time of enrollment.
Note: Checks (money order, cashier’s, or personal) are only accepted for the initial 2-months of premiums. Regional contractors or USFHPs will not accept checks for ongoing payments.

Check/Money Order/Cashier's Check
(Enclose applicable premium payable to contractor on first page.)

PAYMENT AMOUNT: $

Visa/MasterCard Credit or Debit Card:
CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF
CARDHOLDER:

CARDHOLDER
SIGNATURE:

CARDHOLDER
BILLING ADDRESS:

DD FORM 2947-3, SEP 2016

Page 3 of 4 Pages

YOUNG ADULT’S SSN/DBN:

b. MONTHLY RECURRING PREMIUMS: Monthly payments must be recurring electronic payments. You can pay with an allotment
from your sponsor’s retired pay, Electronic Funds Transfer (ETF), or by credit/debit card. You will not receive a monthly bill.
Allotment From Retired Pay
Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.
Other Visa/MasterCard Credit or Debit Card:
CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF
CARDHOLDER:

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

ACCOUNT HOLDER
SIGNATURE

DD FORM 2947-3, SEP 2016

Page 4 of 4 Pages