Tricare Latin America & Canada (Tlac) Prime Enrollment Application Template Sample (Page 2 of 2) in pdf

INSTRUCTIONS

SPONSOR NAME. Last name, first name, middle initial.

write that in this section. If you do not know the number, please write UNKNOWN in

SPONSOR SOCIAL SECURITY NUMBER. This is the SSN of the active duty member

this block.

SEX. M or F.

16. SEX. Please enter the Family Member’s Sex (M for male or F for female)

SPONSOR RESIDING IN: Country in which the sponsor is stationed.

17. RELATIONSHIP TO SPONSOR: Please enter the appropriate response using the samples

DATE OF BIRTH. Enter DOB of sponsor. List by dd/mmm/yyyy (example: 11 Oct

below (For questions please contact the TLAC Support Office):

1962).

SPOUSE

RANK. List rank of sponsor (not pay grade). (example: Army 0-4 should be MAJ).

DAUGHTER

TELEPHONE NUMBER. Sponsor’s work & home phone numbers.

SON

DUTY ADDRESS. Please list Unit, Office Symbol, Installation, APO/FPO, Zip Code

** IF SPOUSE IS ALSO ON ACTIVE DUTY, PLEASE INDICATE IT IN THIS BLOCK**

(Please include the actual country you work in, i.e. Cuba, Paraguay, Canada, etc.)

DEROS/PRD: Enter the sponsor’s date of estimated return from overseas/projected

18. DATE OF BIRTH. List the date of birth for each family member.

rotation date.

(dd/mmm/yyyy) i.e. 01 Jan 1960

10. MAILING ADDRESS. This is your mailing address in Puerto Rico where you currently

19. CURRENTLY RESIDING IN PUERTO RICO. Circle appropriate response.

reside. Include PSC, Box Number, APO and Zip Code.

20. SELECT A PCM FOR EACH FAMILY MEMBER. If living remotely in Puerto Rico

11. SPONSOR BRANCH OF SERVICE: Circle the appropriate selection.

you may choose to enroll to a MTF PCM or use a remote network provider. Contact the

Note: Currently, only Active Duty and their accompanying family members are

nearest TSC for more information. See Prime enrollee TLAC InfoPak for beneficiary cost

authorized to enroll in TLAC Prime.

information concerning use of network/non-network providers in Puerto Rico.

12. E-MAIL ADDRESS: Please provide if one exists for work, home or both. (This will

21. SIGNATURE. Either adult beneficiary must sign and date the form. The signature of the

provide another avenue for important medical benefit information to be distributed)

sponsor or the sponsor’s spouse is required.

13. PRIMARY CARE MANAGER (PCM) SELECTION.

If you have any questions please contact the nearest TRICARE Service Center. The

Mail or deliver completed forms along with a copy of the sponsor’s orders to the nearest

HMHS civilian PCM roster is available at:

TRICARE Service Center at Rodriguez Army

Health Clinic, Fort Buchanan or Naval

Hospital, Roosevelt Roads

14. FAMILY MEMBER NAME. List each family member (last name, first name, middle

initial) who accompanied the sponsor to Puerto Rico, is listed on the sponsor’s original

Or mail to:

TRICARE Area Office

orders, and/or who will reside within a Military Treatment Facility's catchment area in

LATLAC – B38802 (Enrollment)

Puerto Rico. For more catchment area information contact the TSC.

Fort Gordon, GA 30905-5650

15. FAMILY MEMBER SOCIAL SECURITY NUMBER. Please list the Social Security

OR FAX to:

(706) 787-3024 (DSN: 773)

Numbers for each family member. If the family member has not yet been issued a SSN,

OR E-mail completed form (as attached file) to tricare15@amedd.army.mil

PRIVACY ACT STATEMENT

AUTHORITY:

Title 10, USC, Sec. 1095 and 1099; EO 9397

PRINCIPAL PURPOSE(S):

Information will be used to enroll the beneficiary(ies) in TRICARE Latin America & Canada Prime, and to assign Primary Care Managers (PCMs) to each enrollee.

Information will also be used by military treatment facility (MTF) staff and TRICARE contractors to determine eligibility for care and payment of claims.

ROUTINE USE(S):

The information on this form will be released to the MTF staff, TRICARE contractors, and providers of health care.

DISCLOSURE:

Is voluntary, however, failure to provide the information requested may preclude your enrollment in TRICARE Latin America & Canada Prime.