Dd Form 2814 - Pharmacy Redesign Pilot Program Enrollment Page 2

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PRIVACY ACT STATEMENT
AUTHORITY: 44 USC Sec. 101; 10 USC 1079 and 1088; 38 USC Sec. 13; EO Sec. 387.
PRINCIPAL PURPOSE(S): To evaluate for medical care provided by civilian sources to Military Health Services
beneficiaries applying for coverage under the TRICARE Program (32 CFR, Part 198.17).
ROUTINE USE(S): Information from application forms and related documents may be given to the
Department of Defense, Health and Human Services, and/or Transportation consistent with their statutory
administrative responsibilities under the Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); to the Department of Justice for representation of the Secretary of Defense in civil actions; and
to Congressional Offices in response to inquiries made in the request of the person to whom a record
pertains. Appropriate disclosure may be made to other Federal, state, local, and foreign government
agencies, private business entities, and individual providers of care, on matters relating to fraud, program
abuse, program integrity, and civil and criminal litigation related to the operation of the TRICARE Program.
DISCLOSURE: Voluntary; however, failure to provide information will result in denial of enrollment.
PAYMENT INSTRUCTIONS
Mail all TRICARE Pharmacy Redesign Pilot Program enrollment forms to:
Region 3 (Okeechobee, FL area)
Humana Military Healthcare Services
Attn: Pharmacy Pilot Program Enrollment
500 West Main Street
515 Building, 3rd Floor
P.O. Box 740072
Louisville, KY 40201-7472
Region 5 (Fleming, KY area)
Anthem Alliance Health Insurance
Attn: Pharmacy Redesign Pilot Program Enrollment
333 W. First Street, Suite 210
Dayton, OH 45402
Complete credit card information below or attach a check or money order payable to Anthem Alliance Health
Insurance or Humana Military Healthcare Services and include it with your enrollment form.
Credit Card: Type
Visa
Master Card
Other
Credit Card Number
Expiration Date
(MMYY)
Cardholder's Name
Cardholder's Signature
Payment Methods: Indicate the payment method you have chosen, the number of persons enrolling
(i.e. Retiree/Sponsor 1 , Retiree Family Member(s) 1 ), and the total payment you are enclosing.
(2) Semi-annual Payment Method:
(1) Annual Payment Method:
$100.00 per person at the time of enrollment,
$200.00 per person per year.
and $100.00 per person 6 months after each
beneficiary is enrolled into the program.
Retiree/Sponsor
Retiree/Sponsor
Retiree Family Member(s)
Retiree Family Member(s)
Total Payment
$
Total Payment
$
DD FORM 2814 (BACK), NOV 2000
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