Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 6
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7SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAM
E (Last, First, Middle Initial) (Must match DEERS)
SECTION III - OTHER HEALTH INSURANCE
Yes
1. ARE ANY ENROLLING FAMILY MEMBERS OR IS THE RETIREE CURRENTLY COVERED BY OTHER
HEALTH INSURANCE
?
(not a TRICARE Supplement)
No
If Yes, provide the name of the family member and other health insurance, policy number, effective dates, and a
copy of the other health insurance policy and their insurance card.
Yes
2. IS THE RETIREE OR ARE ANY RETIREE FAMILY MEMBERS UNDER AGE 65 AND ELIGIBLE FOR
MEDICARE BASED ON DISABILITY OR END STAGE RENAL DISEASE? If Yes, provide a copy of the
No
Medicare card for each family member that is under the age of 65 and entitled to Medicare.
SECTION IV - REASON FOR PCM CHANGE
2. REASON FOR CHANGE
(X as applicable. If more than one family
1. NAME OF AFFECTED FAMILY MEMBER(S)
member and reason, specify.)
Permanent Change
Dissatisfied
Relocation
of Station (PCS)
Other
(Use Section II to specify change of PCM specialty/
gender preference for more than one family member.)
SECTION V - ACCESS WAIVER
Please read and sign if you are outside the service area.
By signing this application, you indicate your understanding and acceptance that your travel time to the network of
primary care delivery sites may exceed 30 minutes from your home to the delivery site and your travel time for specialty
care may exceed one hour.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
2. RELATIONSHIP TO
3. DATE SIGNED
(YYYYMMDD)
LEGAL GUARDIAN OF BENEFICIARY
SPONSOR
SECTION VI - SIGNATURE
I understand that it is my responsibility to comply with all TRICARE Prime procedures. By signing the form, I certify
that the information on this form is true, accurate and complete. Federal funds are involved in this program and any
false claims, statements, comments or concealment of a material fact may be subject to fine and imprisonment under
applicable Federal law.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
2. RELATIONSHIP TO
3. DATE SIGNED
(YYYYMMDD)
LEGAL GUARDIAN OF BENEFICIARY
SPONSOR
Page 6 of 7 Pages
DD FORM 2876, FEB 2011
ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.
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