Dd Form 2947 - Tricare Young Adult Application Page 3

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SPONSOR'S SSN/DBN:
SECTION III - OTHER HEALTH INSURANCE
18. PLEASE IDENTIFY IF YOU ARE CURRENTLY COVERED BY OTHER HEALTH INSURANCE.
TRICARE Supplement
(no other information is needed)
Medical Insurance: Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Dental Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Vision Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Prescription Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
SECTION IV - ACCESS WAIVER, ATTESTATIONS, AND SIGNATURE (REQUIRED)
I understand that if I selected a Primary Care Manager (PCM) by name, team, or location (MTF or civilian), the TRICARE program will
enroll me with that PCM if capacity exists. If my selected or assigned PCM is greater than a 30 minute drive-time from my residence, or if
I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time
from my residence, and (2) this application constitutes my agreement to waive both the primary care access standard and specialty care
access standard as applicable.
I understand recurring monthly premium payments may be adjusted as necessary based on a desired change in TYA coverage or due to
changes in monthly premium amounts required by law.
I understand that it is my responsibility to comply with all TRICARE Young Adult policies and procedures. By signing this form, I certify
the information provided 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/or imprisonment under applicable Federal law.
COMPLETION IS MANDATORY - X YES OR NO FOR EACH STATEMENT
I am eligible to enroll in an employer-sponsored health plan offered through my employer.
Yes
No
I am married.
Yes
No
19. SIGNATURE OF YOUNG ADULT DEPENDENT APPLICANT
20. DATE SIGNED
(YYYYMMDD)
ENROLLMENT NOTE: Initial enrollment effective date for TRICARE Standard coverage is the 1st of the month following the month the
application is received, or the 1st of the month requested up to 90 days in the future. Effective dates for TRICARE Prime coverage are
based primarily on the 20th of the month rule (applications received by the 20th of the month are effective the first day of the next month).
If a TYA application is received by the contractor or postmarked within 30 days after termination of previous TRICARE coverage, you can
request an effective coverage date immediately following termination of your previous TRICARE coverage. You should confirm enrollment
(and PCM assignment for Prime plans) before obtaining routine medical care by calling your contractor.
DISENROLLMENT NOTE: You may incur a 12 month lock-out from TRICARE Young Adult coverage for failure to pay premiums or for
voluntary termination not associated with gaining employer-sponsored health plan coverage. You may not be allowed to re-enroll in
TRICARE Young Adult for 12 months from the date of the disenrollment.
PAYMENT OPTIONS: See Section V on the next page.
DD FORM 2947, SEP 2016
Page 3 of 4 Pages

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