Dd Form 2854 - Tricare Plus Disenrollment Request Page 2
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2TRICARE PLUS DISENROLLMENT REQUEST
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)
SECTION I - SPONSOR INFORMATION (Must be completed on all applications)
1. Sponsor Social Security Number
2. Sponsor Name (Last, First, Middle Initial)
3. Date of Birth
(SSN) or DoD Benefits Number (DBN)
(YYYYMMDD)
SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT
4.
a. Name (Last, First, Middle Initial)
b. Date of Birth (YYYYMMDD)
c. Reason for Disenrollment (X one)
Other (Explain)
Moved
Loss of TRICARE Eligibility
Request for Voluntary Disenrollment
Death
d. Requested Disenrollment Date
e. Telephone Number (Include area code)
(YYYYMMDD)
(1) Home
(2) Work
f. E-mail Address
X to receive TRICARE e-mails
5.
a. Name (Last, First, Middle Initial)
b. Date of Birth (YYYYMMDD)
c. Reason for Disenrollment (X one)
Other (Explain)
Moved
Loss of TRICARE Eligibility
Request for Voluntary Disenrollment
Death
d. Requested Disenrollment Date
e. Telephone Number (Include area code)
(YYYYMMDD)
(1) Home
(2) Work
SECTION III - SIGNATURE
6. By signing this form, I certify that the information on this form is true, accurate, and complete.
a. Signature
b. Date Signed (YYYYMMDD)
Return ORIGINAL completed form to the Military Treatment Facility where you are currently enrolled.
Keep a copy for your records.
DD FORM 2854, FEB 2014
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