Dd Form 2947 - Tricare Young Adult Application Page 2

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TRICARE YOUNG ADULT OPTION DESIRED:
TRICARE Standard:
Includes dependents of sponsors enrolled in the TRICARE Reserve Select and TRICARE Retired Reserve health plans.
TRICARE Prime:
Where available. Enrollment is not automatic. If eligible, active duty family members may be enrolled in TRICARE Prime Remote
for Active Duty Family Members (TPRADFM).
TRICARE Overseas Program Prime:
For active duty family members only. Must meet specific overseas enrollment criteria. If eligible, may be
enrolled in TRICARE Overseas Prime Remote.
Uniformed Services Family Health Plan (USFHP):
Available in six locations. Submit the completed Enrollment Application to the USFHP
address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the TRICARE website at
SECTION I - SPONSOR INFORMATION
2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
1. SPONSOR'S NAME
(Last, First, Middle Initial) (Must match DEERS)
or DoD BENEFITS NUMBER (DBN)
(XXX-XX-XXXX)
(XXXXXXXXX-XX)
3. SPONSOR IS:
Active Duty
Retired
Selected Reserve
Retired Reserve
Deceased (Go to Section II.)
(X one)
5. SPONSOR'S E-MAIL ADDRESS
4. SPONSOR'S TELEPHONE NUMBER
(Include Area Code)
a. WORK:
b. RESIDENTIAL:
(X box to receive TRICARE e-mails)
6. SPONSOR'S RESIDENCE ADDRESS
(Street, Apartment No., City, State, ZIP Code, Country)
New
7. SPONSOR'S MAILING ADDRESS
(Provide APO or FPO if stationed overseas)
Same as residence
New
8. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT
c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS
b. UNIT IDENTIFICATION CODE (UIC)
(If known)
SECTION II - ENROLLING TRICARE YOUNG ADULT FAMILY MEMBER INFORMATION OR PCM CHANGE
9. FAMILY MEMBER NAME
10. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
11. REQUESTED ACTION:
Enroll
Transfer Enrollment
PCM Change
Disenroll
Effective Date:
12. RESIDENCE ADDRESS
Same as Sponsor
(Provide address, with ZIP Code and
New
Country, if different from Sponsor)
13. MAILING ADDRESS
Same as Residence
(Provide address, with ZIP Code and
New
Country, if different from Sponsor)
15. E-MAIL ADDRESS
14. TELEPHONE NUMBER
(Include Area Code)
(X box to receive TRICARE e-mails)
a. WORK:
b. RESIDENTIAL:
16. PRIMARY CARE MANAGER (PCM) PREFERENCE
(Complete only if selecting a Prime or USFHP plan, or requesting a PCM change. Please
list your first and second choices below. 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. If no PCM preference is indicated,
one will be assigned.)
FULL NAME or MTF/CLINIC
a. 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
b. 2nd CHOICE
MTF
Civilian
Same as Sponsor
c. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
d. PREFERRED PCM GENDER
No Preference
Male
Female
17. REASON FOR DISENROLLMENT OR PCM CHANGE
Relocation
Dissatisfied with PCM
PCS
Have employer-sponsored health care coverage
Marriage
Other:
DD FORM 2947, SEP 2016
Page 2 of 4 Pages

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