Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 6
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
8SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
b. DATE OF BIRTH (YYYYMMDD)
c. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
Same as
Sponsor
d. MAILING ADDRESS (If different from residence address)
Same as
Sponsor
e. RELATIONSHIP TO SPONSOR
Spouse
Former Spouse
Child
f. TELEPHONE NUMBERS
(1) HOME
(2) WORK
(Include Area Code)
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends
upon availability and local MTF policy. Contact your TRICARE Service Center,
preferred MTF or US Family Health Plan Member service for availability of PCMs.)
(Complete all that apply.)
1st CHOICE
(1) PCM NAME
Same as Sponsor
MTF/CLINIC
2nd CHOICE
(If known)
Same as Sponsor
No Preference
Flight Medicine
Pediatrics
(2) PCM
Family/General
SPECIALTY
Internal Medicine
Practice
(3) PREFERRED
No Preference
Male
Female
PCM GENDER
a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
b. DATE OF BIRTH (YYYYMMDD)
c. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
Same as
Sponsor
d. MAILING ADDRESS (If different from residence address)
Same as
Sponsor
e. RELATIONSHIP TO SPONSOR
Spouse
Former Spouse
Child
(1) HOME
(2) WORK
f. TELEPHONE NUMBERS
(Include Area Code)
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends
upon availability and local MTF policy. Contact your TRICARE Service Center,
preferred MTF or US Family Health Plan Member service for availability of PCMs.)
(Complete all that apply.)
1st CHOICE
(1) PCM NAME
Same as Sponsor
MTF/CLINIC
2nd CHOICE
(If known)
Same as Sponsor
No Preference
Flight Medicine
Pediatrics
(2) PCM
Family/General
SPECIALTY
Internal Medicine
Practice
(3) PREFERRED
No Preference
Male
Female
PCM GENDER
DD FORM 2876, MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 6 of 8 Pages
CARBON COPY: RETAIN FOR YOUR RECORDS.
Reset
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business