Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm) Page 2
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5SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED:
TRICARE Prime: Active duty service members (ADSM) are required to enroll in TRICARE Prime. Please note that enrollment
is not automatic.
TRICARE Prime Remote: If eligible, you may be enrolled in TRICARE Prime Remote (TPR) or TRICARE Prime Remote for
Active Duty Family Members (TPRADFM).
TRICARE Overseas Program Prime: Dependents 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
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
8. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT
c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS
b. UNIT IDENTIFICATION CODE (UIC)
(If known)
9. REQUESTED ACTION
(X one)
None
Enroll
Transfer Enrollment
PCM Change
Disenroll
(go to Section II)
Effective Date:
10. SPONSOR'S PRIMARY CARE PCM PREFERENCE (Please list your first and second choices below. Honoring your preference
depends upon availability and local Military Treatment Facility (MTF) policy. Contact your TRICARE Service Center, preferred
MTF, or US Family Health Plan Member Services (non-active duty only) for availability of PCMs.)
a. 1st CHOICE
FULL NAME or MTF/CLINIC
MTF
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, MAY 2013
Page 2 of 5 Pages
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