Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 3
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7MAILING INSTRUCTIONS
1. For enrollment or PCM changes in TRICARE Prime/TRICARE Prime Remote, submit the completed
Application/PCM Change Form to the address below. (For enrollment or PCM changes in the US Family Health
Plan please see instruction 3 above.
)
Health Net Federal Services, LLC
PO Box 870143
Surfside Beach, SC 29587-9743
Applications can be mailed to the contractor identified above or dropped off at a TRICARE Service Center
(TSC). Contact the local TSC in person or call the telephone number listed below in instruction 3 to determine when
your new or transferred enrollment will begin.
2. For additional information on TRICARE, contact the local TRICARE Service Center (TSC) or visit the TMA
website at
3. For enrollment assistance, please call
Health Net Federal Services, LLC
at
877-TRICARE (877-874-2273).
PAY INSTRUCTIONS
1. If you have elected monthly allotment from retired pay as the payment method for your TRICARE Prime
enrollment fees, you must also complete and submit the allotment authorization letter with your application. If you
select this type of payment, you must make the first quarterly payment by check, credit card or money order at the
time of application.
2. If you elected electronic funds transfer (EFT) as the payment method for your TRICARE Prime enrollment fees,
ensure you provide your banking information in Section VII, Part B of the enrollment application form. If you select
this type of payment, you must make the first quarterly payment by check, credit card or money order at the time of
application.
3. If you elected credit card as the method for your initial TRICARE Prime enrollment, ensure you provide your
credit card information in Section VII, Part C of the enrollment application form. These payments are made either
quarterly or annually.
Page 3 of 7 Pages
DD FORM 2876, FEB 2011
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