Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm) Page 2

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SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED:
TRICARE Prime: Active duty service members have to enroll in TRICARE Prime. (Enrollment is not automatic.)
TRICARE Prime Remote: If eligible, you may be enrolled in TRICARE Prime Remote or TRICARE Prime Remote for
Active Duty Family Members.
TRICARE Overseas Program Prime: Family members must be command sponsored and meet specific enrollment criteria of
the overseas area. If eligible, you may be enrolled in TRICARE Overseas Program Prime Remote. Retirees are not eligible for
TRICARE Overseas Program Prime.
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
SECTION I - SPONSOR INFORMATION
2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
1. SPONSOR'S NAME
(Last, First, Middle Initial) (Must match DEERS)
or DoD BENEFITS NUMBER (DBN)
(XXX-XX-XXXX)
(XXXXXXXXX-XX)
3. SPONSOR IS:
Active Duty
Retired
Deceased
Unremarried Former Spouse
(X one)
(Go to Section II.)
5. SPONSOR'S E-MAIL ADDRESS
6. SPONSOR'S
4. SPONSOR'S TELEPHONE NUMBER
(Include Area Code)
DATE OF BIRTH
a. WORK:
c. CELL:
(YYYYMMDD)
b. HOME:
7. SPONSOR'S RESIDENCE ADDRESS
New
(Street, Apartment No., City, State, ZIP Code, Country)
8. SPONSOR'S MAILING ADDRESS
Same as residence
New
(Provide APO or FPO if stationed overseas)
9. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT
c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS
b. UNIT IDENTIFICATION CODE (UIC)
(If known)
10. SPONSOR'S REQUESTED ACTION
(X one)
None
Enroll
Transfer Enrollment
PCM Change
Disenroll (Non-AD only)
(go to Section II)
Effective Date Requested:
11. SPONSOR'S PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability
and your uniformed service guidelines. Review PCM options online or call your Regional Contractor, preferred MTF, or USFHP
member services (non-active duty only) for availability of PCMs.)
a. 1st CHOICE
FULL NAME or MTF/CLINIC
PRP
MTF
(ADSM)
Civilian
b. 2nd CHOICE
FULL NAME or MTF/CLINIC
MTF
Civilian
Family/General Practice
Flight Medicine
c. PCM SPECIALTY
No Preference
Internal Medicine
d. PREFERRED PCM GENDER
No Preference
Male
Female
DD FORM 2876, JUL 2016
Page 2 of 5 Pages

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