Dd Form 2814 - Pharmacy Redesign Pilot Program Enrollment
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PHARMACY REDESIGN PILOT PROGRAM ENROLLMENT
OMB No. 0720-0023
(Read Privacy Act Statement and Payment Instructions on back before completing this form.)
Expires Jul 31, 2003
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0720-0023). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS ON BACK.
1. SPONSOR INFORMATION
a. NAME (Last, First, Middle)
b. SOCIAL SECURITY
c. DATE OF BIRTH
d. SEX (X one)
NUMBER
(YYYYMMDD)
MALE
FEMALE
e. DECEASED (X one)
f. SPONSOR ENROLLING (X one)
YES
NO
YES
NO
g. ADDRESS
(1) STREET (Include apartment number)
(2) CITY
(3) STATE
(4) ZIP CODE
h. TELEPHONE NUMBERS (Include area code)
i. OTHER HEALTH INSURANCE (X one)
(1) HOME
(2) WORK
YES (If Yes, complete Item 3.)
NO
(2) ADDRESS (Street, City, State, ZIP Code)
(3) TELEPHONE NUMBER
j. IN CASE OF EMERGENCY, CONTACT:
(Include area code)
(1) NAME (Last, First, Middle Initial)
2. FAMILY MEMBER ENROLLMENT (List all family members requesting enrollment. All family members must be registered in DEERS.)
(Use additional pages if necessary.)
a. (1) NAME (Last, First, Middle)
(2) SOCIAL SECURITY
(3) DATE OF BIRTH
(4) RELATIONSHIP TO
NUMBER
(YYYYMMDD)
SPONSOR
(5) ADDRESS (f different from sponsor) (Street, City,
(6) TELEPHONE NUMBERS (If different from
(7) OTHER HEALTH
State, ZIP Code)
sponsor) (Include area code)
INSURANCE (X one)
(a) HOME
(b) WORK
YES (If Yes, complete
Item 3.)
NO
(b) ADDRESS (Street, City, State, ZIP Code)
(c) TELEPHONE NUMBER
(8) IN CASE OF EMERGENCY, CONTACT:
(Include area code)
(a) NAME (Last, First, Middle Initial)
b. (1) NAME (Last, First, Middle)
(2) SOCIAL SECURITY
(3) DATE OF BIRTH
(4) RELATIONSHIP TO
NUMBER
(YYYYMMDD)
SPONSOR
(5) ADDRESS (f different from sponsor) (Street, City,
(6) TELEPHONE NUMBERS (If different from
(7) OTHER HEALTH
State, ZIP Code)
sponsor) (Include area code)
INSURANCE (X one)
(a) HOME
(b) WORK
YES (If Yes, complete
Item 3.)
NO
(b) ADDRESS (Street, City, State, ZIP Code)
(c) TELEPHONE NUMBER
(8) IN CASE OF EMERGENCY, CONTACT:
(Include area code)
(a) NAME (Last, First, Middle Initial)
HEALTH
3. OTHER
INSURANCE (Complete only if you have other HEALTH insurance.)
a. INSURANCE COMPANY NAME
c. POLICY NUMBER
d. EXPIRATION DATE
b. TYPE OF COVERAGE
(YYYYMMDD)
(X one)
FULL
SUPPLEMENTAL
e. ADDRESS (Street, City, State, ZIP Code)
f. TELEPHONE NUMBER
g. DOES YOUR POLICY HAVE PRESCRIPTION DRUG
(Include area code)
COVERAGE? (X one)
YES
NO
4. SPONSOR OR ENROLLEE SIGNATURE
5. DATE SIGNED (YYYYMMDD)
DD FORM 2814, NOV 2000
PREVIOUS EDITION IS OBSOLETE.
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