Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 4
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7TRICARE PRIME ENROLLMENT APPLICATION AND
PRIMARY CARE MANAGER (PCM) CHANGE FORM
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
SECTION I - SPONSOR INFORMATION
X one:
US Family
Prime
Prime Remote
Transfer
Split
Health Plan
PCM Change
Enrollment
Enrollment
Enrollment
Enrollment
Enrollment
1. SPONSOR IS:
(X one)
Active Duty
Retired
Deceased
Former Spouse
(Go to Section II.)
2. SPONSOR SOCIAL SECURITY
3. SPONSOR NAME
4. SPONSOR DATE OF BIRTH
(Last, First, Middle Initial)
NUMBER (SSN)
(Must match DEERS)
(YYYYMMDD)
5. RESIDENCE ADDRESS
a. STREET
b. APARTMENT/
c. CITY
d. STATE e. ZIP CODE
SUITE NO.
6. MAILING ADDRESS
(If different from residence address)
a. STREET
b. APARTMENT/
c. CITY
d. STATE e. ZIP CODE
SUITE NO.
8. CITY AND COUNTRY OF MILITARY ASSIGNMENT
7. SPONSOR TELEPHONE NUMBERS
(Include Area Code)
(OCONUS only)
a. HOME
b. WORK
(
)
(
)
10. UNIT
9. MEMBER'S UNIT
11. ZIP CODE OF
12. E-MAIL ADDRESS
IDENTIFICATION
WORK
CODE (UIC)
ADDRESS
(If known)
13. SPONSOR PRIMARY CARE PCM PREFERENCE (Honoring your preference depends upon availability and local Military
Treatment Facility (MTF) policy. Contact your TRICARE Service Center, preferred MTF, or US Family Health Plan Member Services
for availability of PCMs.) (Complete all that apply.)
1st CHOICE
MTF
a. PCM FULL NAME,
Other
MTF/CLINIC
ADDRESS
2nd CHOICE
MTF
(If known)
Other
No Preference
Flight Medicine
b. PCM SPECIALTY
Family/General Practice
Internal Medicine
c. PREFERRED PCM GENDER
No Preference
Male
Female
DD FORM 2876, FEB 2011
Page 4 of 7 Pages
ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.
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