Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 5

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SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME
(Last, First, Middle Initial) (Must match DEERS)
SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE
(Use additional copies of this page to continue as necessary)
1.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RESIDENCE ADDRESS
Same as Sponsor
(1) STREET
(2) APARTMENT/
(3) CITY
(4) STATE (5) ZIP CODE
SUITE NO.
d. MAILING ADDRESS
Same as Sponsor
(If different from residence address)
(1) STREET
(2) APARTMENT/
(3) CITY
(4) STATE (5) ZIP CODE
SUITE NO.
e. RELATIONSHIP TO
g. E-MAIL ADDRESS
f. TELEPHONE NUMBERS
(Include Area Code) (If different from sponsor)
SPONSOR
(1) HOME
(2) WORK
Spouse
Child
(
)
(
)
h. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends upon availability and local MTF policy.
Contact your TRICARE Service Center, preferred MTF or US Family Health Plan Member service for availability of PCMs.) (Complete
all that apply.)
1st CHOICE
Same as
Sponsor
(1) PCM
MTF
FULL NAME
Other
MTF/CLINIC
2nd CHOICE
ADDRESS
Same as
Sponsor
(If known)
MTF
Other
(2) PCM SPECIALTY
Family/General Practice
No Preference
Flight Medicine
Pediatrics
Internal Medicine
(3) PREFERRED PCM GENDER
No Preference
Male
Female
2.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RESIDENCE ADDRESS
Same as Sponsor
(1) STREET
(2) APARTMENT/
(3) CITY
(4) STATE (5) ZIP CODE
SUITE NO.
d. MAILING ADDRESS
Same as Sponsor
(If different from residence address)
(1) STREET
(2) APARTMENT/
(3) CITY
(4) STATE (5) ZIP CODE
SUITE NO.
e. RELATIONSHIP TO
g. E-MAIL ADDRESS
f. TELEPHONE NUMBERS
(Include Area Code) (If different from
SPONSOR
(1) HOME
(2) WORK
Spouse
Child
(
)
(
)
h. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends upon availability and local MTF policy.
Contact your TRICARE Service Center, preferred MTF or US Family Health Plan Member service for availability of PCMs.) (Complete
all that apply.)
1st CHOICE
Same as
Sponsor
(1) PCM
MTF
FULL NAME
Other
MTF/CLINIC
2nd CHOICE
ADDRESS
Same as
Sponsor
(If known)
MTF
Other
(2) PCM SPECIALTY
No Preference
Flight Medicine
Pediatrics
Family/General Practice
Internal Medicine
(3) PREFERRED PCM GENDER
No Preference
Male
Female
Page 5 of 7 Pages
DD FORM 2876, FEB 2011
ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.

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