Tricare Ohi Questionnaire Page 2
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2PGBA, LLC
3. Prior OHI Status - Complete only if you or any of your family members have had OHI within the last 12 months, but do
not have coverage now.
Policy Holder Name:
Policy Number:
_
Name of Carrier:
_
Carrier's Address and Phone No:
_
Effective Date:
Expiration Date:
_
Please indicate type of coverage: HMO/PPO_Single
__
Group__
Private __
Medicare __
Supplemental_
Medicaid/MediCal __
Other:
_
Does this coverage have pharmacy benefits?
Yes ---,- __
No
Does this coverage have any other benefit riders? __
Yes __
No
If yes, please indicate which one(s):
_
Name of
Member 10:
Covered Member:
Date of Birth:
Sex:
Effective:
Expiration: (if
different)
_1_1-
_1_1-
_1_1-
_1_1-
_1_1-
The statements made above are true and correct to the best of my knowledge. I understand that federal laws [8 U.S.C.
and 100] provide for criminal penalties for submitting or making false, fictitious or fraudulent statements or claims on any
matter within the jurisdiction of any department or agency of the United States. I further understand that copies of the laws
cited may be obtained from Uniformed Services legal offices, public libraries and many Health Benefit Advisors.
Relationship to TRICARE Sponsor
Date
Your Signature
If mailing OHI with Prime Enrollment form, mail to:
If mailing OHI form separately, mail to:
Humana Military Healthcare Services
PO BOX 740061
Louisville KY 40201-7461
TRICARE South Region
Customer Service Dept.
PO Box 7032
Camden, SC 29020-7032
Fax (866)836-9535
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