SPONSOR'S SSN/DBN:
SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE (Use additional copies of this page as necessary)
12.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
Effective Date
c. REQUESTED ACTION
:
Enroll
Transfer Enrollment
PCM Change
Disenroll
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Same as Sponsor
New
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(1) WORK:
(2) HOME:
(3) CELL:
g. PCM PREFERENCE
(Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
b. DATE OF BIRTH
13.a. FAMILY MEMBER NAME
(YYYYMMDD)
(Last, First, Middle Initial) (Must match DEERS)
Effective Date
Enroll
Transfer Enrollment
PCM Change
Disenroll
c. REQUESTED ACTION:
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Same as Sponsor
New
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(2) HOME:
(3) CELL:
(1) WORK:
g. PCM PREFERENCE
(Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
14.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
Effective Date
Enroll
Transfer Enrollment
PCM Change
Disenroll
c. REQUESTED ACTION:
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
New
Same as Sponsor
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(1) WORK:
(2) HOME:
(3) CELL:
g. PCM PREFERENCE
(Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
DD FORM 2876-1, JUL 2016
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