Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 7
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7SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME
(Last, First, Middle Initial) (Must match DEERS)
SECTION VII - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former spouses.
Retired beneficiaries under age 65 and retiree family members entitled to Medicare Part A must be enrolled in Medicare Part B to
be eligible for enrollment in TRICARE prime. TRICARE enrollment fees are waived for individuals entitled to Medicare Part B, as
reflected in DEERS.
1. PAYMENT FEE
MONTHLY
QUARTERLY
ANNUAL
OPTIONS
(See Notes 1 and 3 below)
(See Note 2 below)
(See Note 2 below)
Single
$19.17
Single
$57.50
Single
$230.00
2. PLAN SELECTION
(X one)
Family
$38.34
Family
$115.00
Family
$460.00
a. Allotment From Retired Pay
VISA or Master Card
VISA or Master Card
(Complete A below)
(Complete C below)
3. PAYMENT
(Complete C below)
METHOD
b. Electronic Funds Transfer
(X one)
(See Note 4)
(Complete B below)
Note 1: If you have elected a monthly payment option (Allotment or Electronic Funds Transfer) please see Pay Instructions on Page
3 for further details regarding establishing monthly payments.
If you have elected Monthly Allotment or Electronic Funds Transfer, the first quarterly payment (Single - $57.50/family - $115.00) is
due at the time of application.
Note 2: Quarterly and annual bills will be sent on a quarterly and annual basis, respectively. Monthly bills will not be sent.
Note 3: Payment by check is limited to the first quarterly installment for beneficiaries who elect allotment or EFT for the monthly
payment option. Make check payable to
Health Net Federal Services
Note 4: Electronic Funds Transfer is for monthly payments only. Arrangement for electronic payments will be the responsibility of
the enrollee. The initial payment cannot be made electronically.
A - MONTHLY ALLOTMENT
I,
choose to have my enrollment fees paid by monthly allotment from my
Uniformed Services retired pay.
(Signature of sponsor)
NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The additional Allotment
Authorization Letter must be submitted with the application. Follow instructions on Premium Allotment Authorization letter and submit
as directed.
B - ELECTRONIC FUNDS TRANSFER
I,
choose to have my enrollment fees paid by electronic funds transfer.
(Signature of account holder)
(1) NAME AND ADDRESS OF FINANCIAL INSTITUTION
(2) TELEPHONE NUMBER OF
FINANCIAL INSTITUTION
(Include Area Code)
(
)
(4) ACCOUNT NUMBER
(5) BANK OR ABA ROUTING NO.
(3) ACCOUNT INFORMATION
(X)
Checking
Savings
(Attach voided check)
(6) NAME ON ACCOUNT
C - CREDIT CARD
choose to have my initial enrollment fees billed to my credit card.
I,
(Annual and Quarterly initial payments only)
(Signature of card holder)
NOTE: This is not a reoccurring payment. You are responsible for all subsequent fees when paying with a credit card.
(1) NAME ON CREDIT CARD
(2) CREDIT CARD NUMBER
(3) EXPIRATION DATE
(MMYY)
DD FORM 2876, FEB 2011
Page 7 of 7 Pages
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