Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 5
Download a blank fillable Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8TRICARE PRIME ENROLLMENT APPLICATION AND
PCM CHANGE FORM
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
Prime
Prime Remote
US Family Health
PCM
X
Enrollment
Enrollment
Plan Enrollment
Change
one:
1. SPONSOR SOCIAL SECURITY NUMBER (SSN)
2. SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
3. SPONSOR DATE OF BIRTH (YYYYMMDD)
Active Duty
Retired
4. SPONSOR IS:
Deceased
(X one)
Former Spouse
(Go to Section II.)
5. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
ghmbn
6. MAILING ADDRESS (If different from residence address)
a. HOME
b. WORK
7. SPONSOR TELEPHONE NUMBERS
(Include Area Code)
8. CITY AND COUNTRY OF MILITARY ASSIGNMENT (OCONUS only)
9. MEMBER'S UNIT AND UNIT IDENTIFICATION CODE (UIC) (If known)
10. ZIP CODE OF WORK ADDRESS
11. E-MAIL ADDRESS
12. SPONSOR'S
New Enrollment
PCM Change
None
ACTION (X one)
13. SPONSOR PRIMARY CARE MANAGER (PCM) PREFERENCE (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 for availability of PCMs.) (Complete all that apply.)
1st CHOICE
a. PCM NAME
MTF/CLINIC
2nd CHOICE
(If known)
No Preference
Flight Medicine
b. PCM
Family/General
SPECIALTY
Internal Medicine
Practice
c. PREFERRED
No Preference
Male
Female
PCM GENDER
DD FORM 2876. MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 5 of 8 Pages
CARBON COPY: RETAIN FOR YOUR RECORDS.
Reset
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business