Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 7
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8SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
Yes
1. IS THE RETIREE OR ARE ANY RETIREE FAMILY MEMBERS ELIGIBLE FOR
MEDICARE BASED ON DISABILITY OR END STAGE RENAL DISEASE?
No
If Yes, provide a copy of the Medicare card for each family member that is under the age
of 65 and entitled to Medicare.
2. ARE ANY ENROLLING FAMILY MEMBERS OR IS THE RETIREE
Yes
CURRENTLY COVERED BY OTHER HEALTH INSURANCE (not a TRICARE
No
Supplement)?
If Yes, provide the name of the other health insurance and the insurance identification
number:
REASON FOR CHANGE (X one per affected family member)
Name
Other (Explain)
Move
Name
Other (Explain)
Move
Name
Other (Explain)
Move
Name
Other (Explain)
Move
Please read and sign only if you are outside the service area.
Your enrollment application indicates that your current address is outside the service
area. You may travel to a location where there is a provider network and enroll at that
location. However, since you live outside the service area, by signing below, you
indicate that your travel time to the network of primary care delivery sites may exceed
30 minutes from your home to the delivery site and your travel time for specialty care
may exceed one hour.
SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL
DATE SIGNED
GUARDIAN OF BENEFICIARY
(YYYYMMDD)
I understand that it is my responsibility to comply with all TRICARE Prime
procedures. By signing the form, I certify that the information on this form is true,
accurate and complete. Federal funds are involved in this program and any false claims,
statements, comments or concealment of a material fact may be subject to fine and
imprisonment under applicable Federal law.
SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL
DATE SIGNED
GUARDIAN OF BENEFICIARY
(YYYYMMDD)
DD FORM 2876, MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 7 of 8 Pages
CARBON COPY: RETAIN FOR YOUR RECORDS.
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