TRICARE Select Enrollment, Disenrollment, and Change Form

TRICARE Select Enrollment, Disenrollment, and Change Form – OMB Control Number

0720-0061

Screenshot #1 – BWE Dashboard

S creenshot #2 – Select Family Members to Enroll

S creenshot #3 – Select QLE

Screenshot #4 – Confirm Address

Screenshot #5 – Check Compliance Boxes

Screenshot #6 – Select A Plan

Screenshot #7 – Verify Plan and Contractor Information

S creenshot #8 – Collect Premiums

Screenshot #9 – Confirm Premium Information

Screenshot #10 – Confirm Enrollment Information

Screenshot #11 – Print Enrollment Form