Dd Form 2853, Tricare Plus Enrollment Application, February 2014 Page 2
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2TRICARE PLUS ENROLLMENT APPLICATION
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)
SECTION I - SPONSOR INFORMATION (Must be completed on all applications)
1. Sponsor Social Security Number
2. Sponsor Name (Last, First, Middle Initial)
3. Date of Birth
(SSN) or DoD Benefits Number (DBN)
(YYYYMMDD)
SECTION II - INDIVIDUAL ENROLLMENTS
4. Sponsor Requesting Enrollment
a. Mailing Address (Street/P.O. Box, Apartment Number,
b. Residence Address (If different from mailing address)
City, State, ZIP Code)
c. Telephone Number
(1) Home:
(2) Work:
(Include area code):
X to receive TRICARE e-mails
d. Sponsor's E-mail Address:
e. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice
(2) Second Choice
X if under the care of this provider or MTF
X if under the care of this provider or MTF
For Government Use Only
5. Enrolling Family Members
a. Name (Last, First, Middle Initial)
b. Date of Birth (YYYYMMDD)
c. Mailing Address (Street/P.O. Box, Apartment Number,
d. Residence Address (If different from mailing address)
City, State, ZIP Code)
X if same as sponsor
X if same as sponsor
e. Telephone Number
(1) Home:
(2) Work:
(Include area code):
f. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice
(2) Second Choice
X if under the care of this provider or MTF
X if under the care of this provider or MTF
For Government Use Only
SECTION III - SIGNATURE
6. I understand that TRICARE Plus:
(1) is a military treatment facility primary care enrollment program, not a comprehensive health plan; (2) does not guarantee
access to specialty care at the military treatment facility where the beneficiary is enrolled; (3) enrollees may have out-of-pocket
expenses for civilian health care; (4) enrollment at this military treatment facility is not transferable to another military treatment
facility; and (5) by enrolling in TRICARE Plus I will be disenrolled from any other TRICARE enrollment program.
By signing this form, I certify that the information on this form is true, accurate and complete.
a. Signature
b. Date Signed (YYYYMMDD)
Return ORIGINAL completed form to the Military Treatment Facility where you are requesting treatment.
Keep a copy for your records.
DD FORM 2853, FEB 2014
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