DD2497-2 TRICARE Young Adult Application

CUI (when filled in)
OMB No. 0720-0049
OMB approval expires
January 31, 2025

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
This statement informs you of the purpose for collecting personal information required by the TRICARE Young Adult Program and how it will be used.
AUTHORITY: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Manual (DoDM)
6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN).
PURPOSE: This form to collect information necessary to process your request for coverage, to terminate coverage, or to change your provider.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be
disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and others performing or working for the Federal Government when
necessary to accomplish an agency function related to this System of Records; to the Department of Health and Human Services, other federal agencies, and academic
institutions for the purposes of public health activities and conducting research; For a complete listing of the Routine Uses for this system, refer to the below hyperlinked
SORN.
APPLICABLE SORN: Defense Manpower Data Center (DMDC) 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS) (May 31, 2022; 87 FR 32384) https://
dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DMDC-02-DoD.pdf?ver=2019-12-09-111827-743
DISCLOSURE: Voluntary; If you choose not to provide the requested information, there may be an administrative delay; however, care will not be denied and no penalties
will be imposed.

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.
Sponsor
Status

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

(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 to another TYA plan, or request a change in an assigned
Primary Care Manager (PCM) by logging into the Beneficiary Web Enrollment (BWE) website at http://milconnect.dmdc.osd.mil.
MAILING THE FORM:
For manual enrollment, disenrollment, or PCM changes in a TRICARE Young Adult plan, complete and submit the form to the address below.
Forms may be mailed to the contractor identified below. Call your Contractor to determine when your new or transferred enrollment will begin.
Contractor for actions effective prior to January 1, 2025:

Contractor for actions effective on/after January 1, 2025:

Address:

Address:

Phone Number:

Phone Number:

Fax Number:

Fax Number:

Website:

Website:

Uniformed Services Family Health Plan (USFHP) (Include locations, addresses and telephone numbers.) Website: www.tricare.mil/usfhp
USFHP

Pacific Medical Centers

PO Box 169001,
Irving, TX 75016

PO Box 84985
Seattle, WA 98124

Phone: 1-800-678-7347

Phone: 1-888-958-7347 option 1

FAX: 1-210-766-8854

FAX: 1-206-326-2458

DD FORM 2947-2, JAN 2023
PREVIOUS EDITION IS OBSOLETE.

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Controlled by: TRICARE Health Plan Division
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Category: INFOSEC/OPSEC/PII
Distribution/DISTRO: FEDCON
POC: dha.ncr.healthcare-ops.mbx.thp-policy-and-programs-branch@health.mil

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YOUNG ADULT SSN/DBN:
TRICARE YOUNG ADULT OPTION DESIRED:
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).
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)

Active Duty

3. SPONSOR IS: (X one)

Retired

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

Selected Reserve

Retired Reserve

Deceased (Go to Section II.)

5. SPONSOR'S E-MAIL ADDRESS

4. SPONSOR'S TELEPHONE NUMBER (Include Area Code)
a. WORK:
b. RESIDENTIAL:

(X box to receive TRICARE e-mails)

6. SPONSOR'S RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code, Country)

New

7. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)

Same as residence

New

c. STATE, ZIP CODE AND COUNTY OF WORK ADDRESS

8. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT
b. UNIT IDENTIFICATION CODE (UIC) (If known)

SECTION II - ENROLLING TRICARE YOUNG ADULT FAMILY MEMBER INFORMATION OR PCM CHANGE
9. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)

11. REQUESTED ACTION:

Enroll

Transfer Enrollment

12. RESIDENCE ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)

Same as Sponsor

13. MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)

Same as Residence

10. DATE OF BIRTH (YYYYMMDD)

PCM Change

Disenroll

Effective Date

New

New
15. E-MAIL ADDRESS

14. TELEPHONE NUMBER (Include Area Code)

(X box to receive TRICARE e-mails)

a. WORK:
b. RESIDENTIAL:
16. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime or USFHP plan, or requesting a PCM change. Please
list your first and second choices below. Honoring your preference depends upon availability and local Military Treatment Facility (MTF) policy. Contact
your preferred MTF, or US Family Health Plan Member Services for availability of PCMs. If no PCM preference is indicated, one will be assigned.)
FULL NAME or MTF/CLINIC
a. 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
b. 2nd CHOICE

MTF

c. PCM SPECIALTY

No Preference

Civilian

d. PREFERRED PCM GENDER

Same as Sponsor
Family/General Practice

Internal Medicine

Pediatrics

No Preference

Male

Female

17. REASON FOR DISENROLLMENT OR PCM CHANGE
Have employer-sponsored health care coverage

DD FORM 2947-2, JAN 2023
PREVIOUS EDITION IS OBSOLETE.

Relocation

Dissatisfied with PCM

Marriage

Other:

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Flight Medicine

PCS

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YOUNG ADULT SSN/DBN:

SECTION III - OTHER HEALTH INSURANCE
18. 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:

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.

19. SIGNATURE OF YOUNG ADULT DEPENDENT APPLICATION

20. 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, you may request your TYA coverage
to start 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 https://
milconnect.dmdc.osd.mil
DISENROLLMENT NOTE: You may incur a lock-out from TRICARE Young Adult coverage for failure to pay premiums or for
voluntary termination not associated with gaining employer-sponsored health plan coverage.
PAYMENT OPTIONS: See Section V on the next page.
DD FORM 2947-2, JAN 2023
PREVIOUS EDITION IS OBSOLETE.

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YOUNG ADULT SSN/DBN:

SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS
21. 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 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.
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:
b. RECURRING AUTOMATED MONTHLY PREMIUMS (Recurring monthly premiums must be paid via a Recurring Credit Charge on a Visa/MasterCard credit
or debit card, or an Electronic Funds Transfer from a checking or savings account. All options are initiated through and maintained by your servicing
contractor.)
Payment Options
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
TELEPHONE NUMBER OF
FINANCIAL INSTITUTION

NAME ON ACCOUNT
ACCOUNT NUMBER

BANK OR ABA ROUTING NUMBER

ACCOUNT HOLDER
SIGNATURE
My Signature authorizes the servicing 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 fifth business day based on payment option selected. This authorization will
remain in force unless cancelled by me, my servicing contractor, or my financial institution. I understand a $20 administrative fee may be assessed for any
payments returned due to insufficient or unavailable funds.

DD FORM 2947-2, JAN 2023
PREVIOUS EDITION IS OBSOLETE.

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