Dd Form 2877 - Tricare Prime Disenrollment Request Page 3
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3SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT
(Continued)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
Moved
(Explain)
Other Health Insurance
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
Moved
Other Health Insurance
(Explain)
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
(Explain)
Moved
Other Health Insurance
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
SECTION III - SIGNATURE
By signing this form, I certify that the information on this form is true, accurate and complete. Federal funds are
involved in this program and any false claims, statements, comments or concealment of a material fact may be subject
to fine and imprisonment under applicable Federal law. I understand that by voluntarily disenrolling from TRICARE
Prime, TRICARE Prime Remote or US Family Health Plan, prior to the annual renewal, that I will not be allowed to
reenroll in TRICARE Prime, TRICARE Prime Remote, or US Family Health Plan for the 12 month period following my
disenrollment.
(E-1 through E-4 exempt from lockout period).
SIGNATURE
DATE SIGNED
DD FORM 2877, FEB 2011
Page 3 of 3 Pages
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