Dd Form 2877 - Tricare Prime Disenrollment Request
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TRICARE PRIME DISENROLLMENT REQUEST
OMB No. 0720-0008
Jul 31, 2013
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 5 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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (0720-0008). 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 REQUEST TO THE ABOVE ORGANIZATION.
SEND YOUR REQUEST TO THE ADDRESS SHOWN IN THE INSTRUCTIONS.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1079 and 1086; 32 U.S.C. Chapter 17; 32 CFR 199.17; 45 CFR Parts 160 and 164, Health Insurance
Portability and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to disenroll from TRICARE Prime, TRICARE
Prime Remote or the Uniformed Services Family Health Plan, as requested by the individual.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as
amended, these records may specifically be disclosed outside the Department of Defense as a routine use pursuant to 5 U.S.C.
552a(b)(3) as follows: to the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and to other
Federal, State, local, or foreign government agencies, and to private business entities, including entities under contract with the
Department of Defense and individual providers of care, on matters relating to eligibility, claims pricing and payment, fraud, program
abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or
criminal litigation.
DISCLOSURE: Voluntary; however, failure to provide information may result in continued enrollment and responsibility for payment
of applicable enrollment fees.
This form is for eligible beneficiaries whose enrollment in TRICARE Prime, TRICARE Prime Remote, or US Family
Health Plan is voluntary. Do not use this form if transferring enrollment to another region. Contact the
contractor in your new region to request an enrollment form.
GENERAL INSTRUCTIONS
1. For TRICARE Prime and TRICARE Prime Remote disenrollments, submit your completed disenrollment
request to the TRICARE contractor in your region or the TRICARE Service Center. For US Family Health Plan, see
instruction 2 below.
TRICARE West Region
PO Box 105492
Atlanta, GA 30348-5492
2. For US Family Health Plan disenrollments, submit your completed disenrollment request to the US Family
Health Plan facility where you are currently enrolled. For information on US Family Health Plan, visit the US Family
Health Plan website at , or please call
1-877-988-9378
3. Families with more than six members need multiple copies of page 2.
4. Print all information in blue or black ink. Make sure the applicable information is complete and accurate.
5. Make sure all personal and family information matches that in the Defense Enrollment Eligibility Reporting System
(DEERS). To check your DEERS information, call the Support Office at 1-800-538-9552 or log on to
and refer to your name as printed on your military ID card.
6. Sign and date the request (Section III).
NOTE: For some enrollees, you may incur a 12 month lock-out from TRICARE Prime. You may not be allowed
to re-enroll in TRICARE Prime for 12 months from the date of the disenrollment. This one-year period does
not apply to any dependent whose sponsor is in the grade of E-1 to E-4.
7. Please keep a copy of the completed request for your records. If faxed, please maintain a confirmation of fax.
8. For information on TRICARE, contact the local TRICARE Service Center (TSC) or visit the TRICARE website at
, or call 1-800-TRICARE or 1-800-874-2273.
DD FORM 2877, FEB 2011
PREVIOUS EDITION IS OBSOLETE.
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