Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 8
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8SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
SECTION VII - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former
spouses.
1. Retired beneficiaries and retiree family members entitled to Medicare Part A and Medicare
Part B must be enrolled in Medicare Part B to be eligible for enrollment in TRICARE prime.
TRICARE enrollment fees are waived for these retirees and retiree family members if they
provide a copy of their Medicare card as proof of entitlement to Medicare Part A and B and
DEERS reflects their entitlement to Medicare Part A and B.
2. Explain all split enrollments (retiree family enrollment in more than one TRICARE Region) on
a separate sheet of paper.
1. PAYMENT
FEE
MONTHLY
QUARTERLY
ANNUAL
OPTIONS
2. PLAN
Single
$19.17
Single
$57.50
Single
$230.00
SELECTION
Family
$38.34
Family
$115.00
Family
$460.00
(X one)
a. Allotment From
a. Check/Cashiers
a. Check/Cashiers
Retired Pay
Check/Money
Check/Money
3. PAYMENT
(Complete A below)
Order*
Order*
METHOD
b. Electronic Funds
b. VISA or Master
b. VISA or Master
(X one)
Transfer (Complete
Card (Complete
Card (Complete
B below)
C below)
C below)
If you have elected a monthly payment option (Allotment or Electronic Funds Transfer) please
see Pay Instructions on Page 4 for further details regarding establishing monthly payments.
If you have elected Monthly Allotment or Electronic Funds Transfer, the first quarterly payment
is due at the time of application.
NOTE: Quarterly and annual bills will be sent on a quarterly and annual basis, respectively.
Monthly bills will not be sent.
*Make check payable to the (Contractor's Name)
A
choose to have my enrollment fees paid by
I,
monthly allotment from my Uniformed Services
(Signature of sponsor)
retired pay.
NOTE:
Only retired Uniformed Services members may establish an allotment from their retired
pay. Follow instructions on Premium Allotment Authorization letter and submit as directed.
B
I,
choose to have my enrollment fees paid by
electronic funds transfer.
(Signature of account holder)
(1) NAME AND ADDRESS OF FINANCIAL INSTITUTION
(2) TELEPHONE NUMBER OF FINANCIAL INSTITUTION
(Include Area Code)
Savings
Checking
(3) ACCOUNT INFORMATION (X)
(Attach voided check)
(4) ACCOUNT NUMBER
(5) BANK OR ABA ROUTING NUMBER
(6) NAME ON ACCOUNT
choose to have my initial enrollment fees billed to
C
I,
my credit card. (Annual and Quarterly initial
(Signature of card holder)
payments only)
(1) NAME ON CREDIT CARD
(2) CREDIT CARD NUMBER AND EXPIRATION DATE (MMYY)
VISA
Master Card
(3) TYPE OF CARD (X)
DD FORM 2876, MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 8 of 8 Pages
CARBON COPY: RETAIN FOR YOUR RECORDS.
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