Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 3
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8GENERAL INSTRUCTIONS
1. TRICARE Prime - Active duty service members are required to enroll in Prime. Active
duty family members, retirees and their family members are encouraged, but not required,
to enroll in Prime.
2. TRICARE Prime Remote (TPR) is a program for active duty service members and their
family members when the sponsor lives and works over 50 miles or one hour drive from a
Military Treatment Facility (MTF) and the family member lives with the sponsor.
3. Families with more than three members need multiple copies of page 6.
4. Print all information in ink. Make sure the information is complete and accurate.
5. Ensure personal and family information matches information in the Defense Enrollment
Eligibility Reporting System (DEERS). To check your DEERS information, call the Defense
Manpower Data Center (DMDC) Support Office at 1-800-538-9552 and refer to your name
as printed on your military ID card.
If you are an unremarried former spouse, please remember to use your personal SSN as the
sponsor number.
6. There are two address fields for the sponsor and each family member. The Residence
address block should be completed if it is known. If you haven't established a residence at
the time you are completing this form, insert "To be determined." in the Residence address
block and complete the Mailing address block. The Mailing address block is only to be
completed if mail is to be sent to an address other than the Residence address. If the
Mailing address block is blank, all mail will be sent to the Residence address. The
addresses and telephone numbers you include on this form will update DEERS.
It is very important that you update your personal information in DEERS whenever your
residence address, mailing address, telephone number or Medicare status changes. Please
see instruction 5 above.
7. Sign and date the application (Section VI).
8. Please keep a copy of the completed TRICARE Prime Application/PCM Change Form for
your records.
Enrollment in TRICARE Prime requires that all services, except for emergencies, must be
coordinated through the PCM. If not, the beneficiary will be responsible for payment of
charges in accordance with the Point-of-Service (POS) option as described in the TRICARE
Beneficiary Handbook.
DD FORM 2876, MAR 2004
Page 3 of 8 Pages
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