DD Form 2837, "Continued Health Care Benefit Program (CHCBP) Application"

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(Updated 20260710)
OMB No. 0720-0066
OMB approval expires
20261031

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP) APPLICATION

The public reporting burden for this collection of information 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.

PLEASE DO NOT RETURN YOUR APPLICATION TO THE ABOVE ORGANIZATION. RETURN COMPLETED APPLICATION WITH PREMIUM
PAYMENT TO: Humana Military Healthcare Services, Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201.
PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting the personal information required by DD Form 2837, Continued Health Care Benefit Program (CHCBP) Application,
and how it will be used.
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. Chapter 58, Benefits and Services for Members Being Separated or Recently
Separated; Department of Defense Instruction 1341.02, Defense Enrollment Eligibility Reporting System (DEERS) Program and Procedures; and E.O. 9397 (SSN), as amended.
PURPOSE: To collect information necessary to determine eligibility for individual or family coverage under the Continued Health Care Benefit Program (CHCBP).
ROUTINE USE(S): 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 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 will be shared with the CHCBP contractor for determination of eligibility and to provide temporary health care coverage. For a full listing of the
applicable Routine Uses for this system, refer to the applicable SORN.
APPLICABLE SORN: The applicable system of records notice is Defense Manpower Data Center (DMDC) 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS) (May
31, 2022; 87 FR 32384) published at: https://www.federalregister.gov/documents/2022/05/31/2022-11610/privacy-act-of-1974-system-of-records
DISCLOSURE: Providing this information is voluntary; however, failure to provide it may result in denial of your application.

SECTION I - APPLICANT INFORMATION
1. NAME (Last, First, Middle Initial)

2. TELEPHONE NO. (Include Area Code)

3. RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code)

4. MAILING ADDRESS (If different from Residence Address)

5. E-MAIL ADDRESS

X BOX TO RECEIVE BENEFIT RELATED E-MAILS
SECTION II - SPONSOR INFORMATION

6. NAME (Last, First, Middle Initial)

7. DOD BENEFITS NUMBER (DBN) (XXXXXXXXX-XX) OR
SOCIAL SECURITY NUMBER (SSN) (XXX-XX-XXXX)
SECTION III - PERSON(S) TO BE ENROLLED IN CHCBP (Including Applicant)
8.a. NAME
8.b. DBN OR SSN OF
INDIVIDUAL
(Last, First, Middle Initial)
If applying for Family coverage, complete below. Sponsor must enroll.

8.c. DATE OF BIRTH
(YYYYMMDD)

8.d. SEX
(M or F)

SPONSOR

M

F

DEPENDENTS

M

F

M

F

M

F

M

F

M

F

M

F

M

F

SPONSOR

M

F

SPOUSE

M

F

M

F

CHILD

M

F

OTHER

M

F

If applying for Individual coverage, complete appropriate line below:

FORMER SPOUSE
(Submit copy of final divorce decree)

9 . TOTAL THREE-MONTH PREMIUM ENCLOSED: (See www.tricare.mil/chcbp)
$
INDIVIDUAL COVERAGE
FAMILY COVERAGE
PREMIUM PAID IS FOR:
PAID BY:
CHECK
MONEY ORDER (Check/money order payable to the United States Treasury)

Credit/Debit Card

10. APPLICANT'S SIGNATURE AND DATE: By signing this form, the applicant is certifying that the information provided on this form 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
imprisonment under applicable Federal law.
a. SIGNATURE

DD FORM 2837, MAY 2025
PREVIOUS EDITION IS OBSOLETE.

b. DATE SIGNED (YYYYMMDD)

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Controlled by: DHA
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CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC dha.ncr.healthcare-ops.mbx.thp-policy-and-programs-branch@health.mil

CUI (when filled in)

(Updated 20260710)

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP) APPLICATION INSTRUCTIONS
Section I – APPLICANT INFORMATION:
1. Name: (Last, First, Middle Initial) (Must match what’s in the Defense Enrollment Eligibility Reporting System (DEERS).
2. Phone Number: Enter your complete phone number(s) (home, work, mobile), with area code.
3. Residence Address (Street, apartment number, city, state, ZIP code, country). CHCBP sends mail to this address, unless you put something different in
item #4.
4. Mailing Address: Fill this out only if it’s different from your residence address (Item #3).
5. E-Mail: Enter your e-mail address(es). Mark the box if you agree to receive benefit related e-mails.
SECTION II - SPONSOR INFORMATION:
6. Sponsor’s Name: (Last, First, Middle Initial) (Must match what’s in DEERS).
7. DoD BENEFITS NUMBER (DBN) (XXXXXXXXX-XX) or SOCIAL SECURITY NUMBER (SSN) (XXX-XX-XXXX) of the sponsor.

SECTION III - PERSON(S) APPLYING FOR CHCBP (Including yourself):
Fill in the boxes under “Family Coverage” for yourself and other family members. Note: For family coverage, the Sponsor must apply for coverage.
Fill in the box under “Individual Coverage” if you’re the only one applying for CHCBP.
8a. Name (Last, First, Middle Initial): Each person’s full name.
8b. DBN or SSN: Each person's DBN or SSN (see above for sponsor for example). DBN is preferred.
8c. Date of Birth: Each person’s full date of birth.
8d. Sex: Mark each person’s sex: “M” for Male; “F” for Female.
9. Total Three-Month Premium: You have to submit a full 3-month premium with this application. Go to www.tricare.mil/chcbp for current rates. Enter the full
amount you owe. Mark the box for “Individual Coverage” OR “Family Coverage." Mark the “Paid by” box for your “Check” OR “Money Order,” payable to the
“United States Treasury.”
10. Signature and Date: This should be your signature (as the sponsor for the family or as the single person applying). You signature reflects your agreement that
the information on the application is correct. Enter the date you signed the application.
10a. Signature: Here is where you (the sponsor’s or single applicant) sign.
10b. Date signed: The date you signed the form (Year, month, day—YYYYMMDD).
TO PURCHASE OR CHANGE COVERAGE: You may mail or fax this form to the CHCBP contractor. Mailing address is listed on page 1. Fax: 502-322-8108.
You use this same form to apply for coverage or change your CHCBP plan (for example, family to individual if a child ages out). The contractor will notify you
about your coverage status by e-mail or U.S. mail. For any questions call 1-800-444-5445..

DD FORM 2837, MAY 2025
PREVIOUS EDITION IS OBSOLETE.

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