Fillable Dd Form 2947 - Tricare Young Adult Application printable pdf download

OMB No. 0720-0049

TRICARE YOUNG ADULT APPLICATION

OMB approval expires

Oct 31, 2015

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center

Drive, Alexandria, VA 22350-3100 (0720-0049). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN

collection of information if it does not display a currently valid OMB control number.

COMPLETED FORM TO THE FOLLOWING SERVICING CONTRACTOR:

US Family Health Plan - Christus Health

(See the address and phone number on the back of this form)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. Chapter 17, Hospital, Nursing Home, Domiciliary, and Medical Care; 32

CFR Part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); 45 CFR Parts 160 and 164, Health Insurance Portability

and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSES: To obtain information to permit certain former military health care beneficiaries to purchase, transfer, or terminate extended

dependent health care coverage under the TRICARE Young Adult Program.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these records

may specifically be disclosed outside the Department of Defense as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to the Departments of

Veterans Affairs, Health and Human Services and Homeland Security, and to other Federal, State, local, or foreign government agencies, and to

private business entities, including entities under contract with the Department of Defense and individual providers of care, on matters relating to

eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability,

coordination of benefits, and civil or criminal litigation.

DISCLOSURE: Voluntary; however, failure to furnish all requested information may result in denial of the individual's purchase, transfer, or

termination of TRICARE Young Adult Program health plan coverage.

1. TRICARE COVERAGE DESIRED (X one. Based on Uniformed Service sponsor's status.)

TRICARE Prime (where available and if qualified)

TRICARE Standard

TRICARE Overseas Prime (dependent must be command sponsored and meet specific enrollment criteria of the overseas area)

TRICARE Reserve Select (sponsor must be enrolled in TRS)

TRICARE Retired Reserve (sponsor must be enrolled in TRR)

TRICARE Prime Remote for Active Duty Family Members

Uniformed Services Family Health Plan (where available and if

(sponsor must be enrolled in TPR)

qualified)

3. REQUESTED EFFECTIVE/TERMINATION/TRANSFER

2. REQUESTED ACTION (X one)

DATE (YYYYMMDD)

Start coverage (complete all items)

Terminate TYA coverage (complete items 2 - 10, 12-15, and 17):

Have employer-sponsored healthcare

Marriage

Voluntary

Transfer coverage to another TYA Plan (complete items 2 - 10, 11 as needed, and 17). If necessary, recurring monthly premiums will be

adjusted accordingly.

APPLICANT INFORMATION

4. NAME (Last, First, Middle Initial)

5. SOCIAL SECURITY NUMBER (SSN)

6. DATE OF BIRTH

OR DoD BENEFITS NUMBER (If known)

(YYYYMMDD)

8. E-MAIL ADDRESS

7. TELEPHONE NUMBER (Include Area Code)

a. HOME

b. CELLULAR

9. RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code) 10. MAILING ADDRESS (If correspondence, including premium notices,

are to be mailed to an address other than the residence address)

11. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime plan or USFHP.) (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.)

a. PCM FULL NAME,

1st CHOICE

MTF/CLINIC

MTF

ADDRESS

Other

(If known)

2nd CHOICE

MTF

Other

Family/General Practice

b. PCM SPECIALTY

No Preference

Flight Medicine

Internal Medicine

No Preference

Male

Female

c. PREFERRED PCM GENDER

DD FORM 2947, SEP 2012

Adobe Professional 8.0

PREVIOUS EDITION IS OBSOLETE.

Dd Form 2947 - Tricare Young Adult Application

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