Dd Form 2876-2 - Tricare Prime Enrollment, Disenrollment, And Pcm Change Form Page 5

Download a blank fillable Dd Form 2876-2 - Tricare Prime Enrollment, Disenrollment, And Pcm Change Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Dd Form 2876-2 - Tricare Prime Enrollment, Disenrollment, And Pcm Change Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SPONSOR'S SSN/DBN:
SECTION VI - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former spouses.
Retired beneficiaries and retiree family members under age 65 who are entitled to Medicare Part A must be enrolled in Medicare Part
B to be eligible for enrollment in TRICARE Prime. TRICARE Prime enrollment fees are waived for individuals enrolled in Medicare
Part A and Part B, as reflected in DEERS.
PAYMENT OPTIONS: See Sections A, B, and C below for payment options.
Note 1, Monthly Payment: Monthly payments must be recurring payments. You will not receive a monthly bill. If you select the
monthly payment plan, you must make an initial three month payment by check (cashier's or personal check), credit/debit card, or
money order at the time of application. Make checks payable to:
Health Net Federal Services, LLC
Note 2, Quarterly and Annual Payments: You will be billed on a quarterly or annual basis for credit card payments.
(Your Contractor may offer recurring quarterly and/or annual payments.)
Note 3, Personal Check: Payment by check (money order, cashier's or personal) is limited to the initial three month payment only.
Checks received for ongoing payment will not be accepted.
Note 4, Electronic Funds Transfer: EFT is for monthly or quarterly payments only. The initial payment cannot be made via EFT.
Allotment From Retired Pay
Electronic Funds Transfer
MONTHLY
VISA or MasterCard
PAYMENT FEE, PLAN AND
METHOD OPTIONS (Some
INITIAL 3-MONTH PAYMENT:
Check
Money Order
Credit/Debit Card (Section C below)
options are location specific)
VISA or MasterCard
QUARTERLY
ANNUAL
VISA or MasterCard
I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay.
NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The Uniformed Service member must sign
below
. Your Regional Contractor will charge the correct fee amount each month based on your enrollment, individual or family.
(The current rates are at )
B - ELECTRONIC FUNDS TRANSFER
ELECTRONIC FUNDS TRANSFER FOR AUTOMATIC PAYMENTS
Checking (attach voided check)
S
avings
Name and Address of Financial Institution
Name on Account
Telephone Number of Financial Institution
Account Number
ABA Routing Number
NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family.
(The current rates are at )
C - CREDIT/DEBIT CARD
INITIAL 3-MONTH PAYMENT
VISA/MASTERCARD MONTHLY RECURRING PAYMENTS:
CREDIT/DEBIT CARD:
Number
:
Exp. Date (MM/YYYY)
Security Code (3-digit number on reverse side of card)
Name of Cardholder
NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family.
(The current rates are at )
SIGNATURE
My signature authorizes the Regional Contractor to START, CHANGE, or STOP my automated payments as indicated above. Fee amounts, as
determined by TRICARE and subject to change each fiscal year, will be withdrawn between the first and the fifth business day based on the payment
option selected. This authorization will remain in force unless cancelled by me, my Regional Contractor or my financial institution. I understand a
$20.00 administrative fee may be assessed for any payments returned due to insufficient or unavailable funds.
SIGNATURE OF SPONSOR, SPOUSE OR OTHER LEGAL GUARDIAN OF BENEFICIARY
DATE
DD FORM 2876-2, JUL 2016
Page 5 of 5 Pages

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 5