Application For Uniformed Services Identification Card Deers Enrollment (Page 2 of 2) in pdf

The public reporting burden for this collection of information is estimated to average 10 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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports

(0704-0020), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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 COMPLETED FORM TO THIS ADDRESS.

RETURN COMPLETED FORM TO THE UNIFORMED SERVICE ID CARD ISSUING FACILITY.

SECTION VII - PRIVACY ACT STATEMENT

AUTHORITY:

10 U.S.C. ss 1061 - 1065, 1072 - 1074, 1074a - 1074c, 1076, 1076a, 1077, E.O. 9397.

PRINCIPAL PURPOSE(S):

To apply for the Uniformed Services Identification Card and/or DEERS Enrollment.

ROUTINE USE(S):

Information may be released to appropriate business entities, individual providers of care,

and others, on matters relating to claims adjudication, program abuse, utilization review,

professional quality assurance, medical peer review, program integrity, third party liability,

coordination of benefits, and civil and criminal litigation.

To the Department of Health and Human Services, the Department of Veterans Affairs, the

Social Security Administration, and to other Federal, state, and local government agencies

to identify individuals having benefit eligibility in another plan or program.

Applicant information is subject to computer matching within the Department of Defense or

with other Federal or non-Federal agencies. Matching programs are practiced to assure

that an individual eligible under a Federal program is not receiving duplicate benefits from

another program. A beneficiary or former beneficiary who has applied for privileges of a

Federal Benefit Program and has received concurrent assistance under another plan will

be subject to adjustment or recovery of any improper payments made or delinquent debts

owed.

DISCLOSURE:

Voluntary; however, failure to provide information may result in denial of Uniformed

Services Identification Card and/or non-enrollment in the Defense Enrollment Eligibility

Reporting System.

SECTION VIII - CONDITIONS APPLICABLE TO SPONSOR OR APPLICANT

I understand that the actions of the recipient(s) of

as to availability of space, facilities, and the capabilities

the "Uniformed Services Identification Card" issued as a

of the medical staff shall be conclusive.

result of this application are my responsibility insofar as

proper use of the card for benefits and privileges

Reimbursement shall be required for any unauthor-

authorized; i.e., medical and dental care, exchange,

ized medical and dental care furnished at government

commissary,

and

morale,

welfare, and recreation

expense.

Copies of regulations concerning eligibility

programs. I will cause the recipient to surrender the card

requirements are available in the Service Personnel

immediately upon call to do so or when appropriate under

Offices.

applicable regulations, and will notify an agency

designated to grant authorization for privileges and

By signing this document, the sponsor or applicant

facilities in event of any change in status affecting a

certifies that he/she is aware that eligibility for benefits

recipient's eligibility therefor.

under the Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS) terminates for all

I am aware that medical care furnished in uniformed

beneficiaries, except spouses and children of active duty

services facilities is subject to availability of space,

members, and certain disabled beneficiaries under 65,

facilities, and the capabilities of the medical staff to

when the beneficiary becomes eligible for Medicare Part

provide such care.

Determinations made by the

A, Hospital Insurance, through the Social Security

medical officer or contract surgeon, or his/her designee,

Administration.

PENALTY FOR PRESENTING FALSE CLAIMS OR MAKING FALSE STATEMENTS

IN CONNECTION WITH CLAIMS: FINE OF UP TO $10,000 OR

IMPRISONMENT FOR UP TO FIVE YEARS OR BOTH.

(ACT June 25, 1948, 18 U.S. Code 287, 1001)

DD Form 1172 (BACK), SEP 96

USAPA V1.00

Application For Uniformed Services Identification Card Deers Enrollment Page 2

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