Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change

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TRICARE PRIME ENROLLMENT APPLICATION AND
OMB No. 0720-0008
PRIMARY CARE MANAGER (PCM) CHANGE FORM
OMB approval expires
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Jul 31, 2013
Instructions before completing this form.)
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0720-0008). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR APPLICATION TO THE ABOVE ORGANIZATION.
SEND YOUR APPLICATION TO THE ADDRESS SHOWN ON THE APPLICATION INSTRUCTION SHEET.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1079 and 1086, 32 U.S.C. Chapter 17; 32 CFR 199.17; 45 CFR Parts 160 and 164, Health Insurance
Portability and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to enroll in the TRICARE Prime, TRICARE Prime
Remote, or the Uniformed Services Family Health Plan, as requested by the individual.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as
amended, these records may specifically be disclosed outside the Department of Defense as a routine use pursuant to 5 U.S.C.
552a(b)(3) as follows: to the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and to other
Federal, State, local, or foreign government agencies, and to private business entities, including entities under contract with the
Department of Defense and individual providers of care, on matters relating to eligibility, claims pricing and payment, fraud, program
abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or
criminal litigation.
DISCLOSURE: Voluntary; however, failure to provide information may result in the denial of enrollment.
This form is for the following:
- To allow eligible beneficiaries to apply for enrollment in TRICARE Prime, TRICARE Prime Remote (TPR), or US
Family Health Plan.
- Enrollees to change to a new region for the TRICARE programs listed above.
- Enrollees to update their personal contact information to include addresses, phone numbers, and email within the
same region for the TRICARE programs listed above.
Review the eligible categories (1 through 5) below to determine the application sections you must complete.
SECTION
SECTION
SECTION
SECTION
SECTION
SECTION
SECTION
I
II
III
IV
V
VI
VII
ELIGIBLE CATEGORIES
Sponsor
Enrolling
Other
Reason
Access
Enrollment
Information
Family
Health
for PCM
to Care
Signature
Fee
Members
Insurance
Change
Waiver
Payment
Complete if
1. Active Duty Members, Guard and
Complete
you live more
Reserve Component Members called
if
X
X
than 30
changing
or ordered to active duty for more than
minutes from
*
PCM
30 consecutive days.
selected PCM
Complete if
2. Active Duty Family Members
Complete
you live more
(ADFMs) and Survivors of Active
if
X
X
X
X
than 30
Duty (in transitional survivor
changing
minutes from
status).
PCM
*
selected PCM
Complete if
you live
Family Members of Guard and
Complete
3.
more than
Reserve called or ordered to active
if
X
X
X
X
30 minutes
duty for more than 30 consecutive
changing
from
days may be eligible in DEERS.
PCM
*
selected
PCM
4. Eligible retirees, their family
members, survivors and eligible former
Complete if
spouses under 65 years of age who
X
you live
Complete
reside within the 50 United States or
more than
(Must
the District of Columbia.
if
X
X
X
X
30 minutes
include
changing
This includes beneficiaries 65
from
required
PCM
years and over who are NOT
*
selected
payment)
eligible for Medicare Part A on their
PCM
record or their
spouse's record.
X
5. ADFMs, retirees, retired family
Complete
Complete if
you live more
(If not
members, survivors and eligible former
if
X
X
X
X
than 30
enrolled in
spouses who are entitled to Medicare
changing
minutes from
Medicare
*
Part A.
PCM
selected PCM
Part B)
* Complete Section V (Access to Care Waiver) if you live more than 30 minutes from desired PCM.
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 7 Pages
DD FORM 2876, FEB 2011
Adobe Professional 8.0

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