Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm) Page 5
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SECTION VI - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former spouses.
Retired beneficiaries and retiree family members under age 65 who are entitled to Medicare Part A must be enrolled in Medicare Part
B to be eligible for enrollment in TRICARE prime. TRICARE Prime enrollment fees are waived for individuals enrolled in Medicare
Part A and Part B, as reflected in DEERS.
PAYMENT OPTIONS: See Sections A, B, and C below for elective payment options. Your initial enrollment application must include
payment for at least the first three (3) months of coverage. You may pay this amount either by credit card, money order or personal
check. Checks should be made payable to:
USFHP at Pacific Medical Centers
Note 1, Monthly Allotment: If you select the monthly payment plan, you must make an initial three month payment by check,
credit card or money order at the time of application. Monthly bills will not be sent.
Note 2, Quarterly and Annual: Bills will be sent on a quarterly and annual basis for credit card payment. The payments can be
recurring as established by the enrolling contractor.
Note 3, Personal Check: Payment by check is limited to the initial three month payment for beneficiaries who elect allotment or EFT.
Note 4, Electronic Funds Transfer: EFT is for monthly payments only. The initial payment cannot be made electronically.
Allotment From Retired Pay
Electronic Funds Transfer
MONTHLY
VISA or MasterCard
PAYMENT FEE, PLAN AND
METHOD OPTIONS (Some
INITIAL 3-MONTH PAYMENT:
Check
Money Order
Credit Card (Section C below)
options are location specific)
VISA or MasterCard
QUARTERLY
ANNUAL
VISA or MasterCard
A - MONTHLY ALLOTMENT
I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay.
Individual $
Family $
(The current rates are at )
Signature
NOTES: Only retired Uniformed Services members may establish an allotment from their retired pay. An Allotment form is required and must be
submitted with the application. See Note 1 above.
B - ELECTRONIC FUNDS TRANSFER
ELECTRONIC FUNDS TRANSFER FOR AUTOMATIC MONTHLY PAYMENTS
Checking (attach voided check)
Savings
Individual $
Family $
(The current rates are at )
Name and Address of Financial Institution
Name on Account
Telephone Number of Financial Institution
Account Number
ABA Routing Number
Signature
C - CREDIT CARD
INITIAL 3-MONTH PAYMENT
VISA/MASTERCARD MONTHLY RECURRING PAYMENTS:
Individual $
(The current rates are at )
Family $
Number
Exp. Date (MM/YYYY)
VISA/MASTERCARD:
Security Code (3-digit number on reverse side of card)
Name of Cardholder
Cardholder Signature
DD FORM 2876, MAY 2013
Page 5 of 5 Pages
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