Tricare Latin America & Canada (Tlac) Prime Enrollment Application Template Sample
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2T R I C A R E L A T I N A M E R I C A & C A N A D A ( T L A C ) P R I M E E N R O L L M E N T A P P L I C A T I O N ( P u e r t o R i c o ( T P R C ) )
SPONSOR INFORMATION
CAN BE COMPLETED BY ANY ADULT BENEFICIARY. SEE REVERSE FOR DIRECTIONS. PLEASE PRINT CLEARLY.
4. Country Sponsor
5. Date of Birth
1. Sponsor Name (last, first, middle initial)
3. Sex
6. Rank
7. Telephone Numbers
2. Sponsor Social Security Number
Residing in:
(dd/mmm/yyyy)
(787)
Home:
(787)
Duty:
8. Duty Address (Unit, Office Symbol, Station, APO/FPO)
9. DEORS/PRD
10. Mailing Address in Puerto Rico
11. Sponsor Branch of Service (Must be Active
(*required*)
Duty)
Army
Air Force
Navy
Marines
USCG
NOAA/PHS
12. E-Mail Address (if available)
13. Active Duty Primary Care Manager (PCM)/MTF Selection (Please check one)
Please Print Clearly
Rodriguez Army Health Clinic, Fort Buchanan (RAHC)
San Juan Base, Sick Bay (Active Duty Only) (SJSB)
Enter PCM Name for Active Duty Sponsor
:
Active duty only.
(Enter City for Remote Puerto Rico)
Civilian PCM from the HMHS Website (RemPR)
Ramey Clinic, Borinquen (RCB)
( )
FAMILY MEMBER INFORMATION
LIST ALL FAMILY MEMBERS WHO ACCOMPANIED THE SPONSOR TO PUERTO RICO AND ARE APPLYING FOR ENROLLMENT. PLEASE PRINT CLEARLY
20.
15. Family Member’s
16. Sex
17. Relationship
18. Date of Birth
19. Residing in
Family Member PCM Selection
14. Family Member Name (last, first, middle initial)
Social Security Number
( M or F)
to Sponsor
(dd/mmm/yyyy) & Age
Puerto Rico?
(Civilian HMHS PCM from Web)
Yes
Age:
No
(Enter Provider’s Name)
Yes
Age:
No
(Enter Provider’s Name)
Yes
No
Age:
(Enter Provider’s Name)
Yes
No
Age:
(Enter Provider’s Name)
Yes
No
Age:
(Enter Provider’s Name)
Yes
Age:
No
(Enter Provider’s Name)
21. SIGNATURE: “I have read the instructions on the reverse side of this form and
understand the Privacy Act Statement listed there. I further request enrollment for my
SIGNATURE
DATE
listed family members in TRICARE Latin America & Canada Prime.”
Please return this completed application to TLAC Area Office
WITH A COPY OF YOUR ORDERS
(details on back)
(Rev. May 2003)
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