Fillable Dd Form 2947 - Tricare Young Adult Application printable pdf download

OMB No. 0720-0049

TRICARE YOUNG ADULT APPLICATION

OMB approval expires

Mar 31, 2015

The public reporting burden for this collection of information is estimated to average 15 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, 4800 Mark Center Drive, Alexandria,

VA 22350-3100 (0720-0049). 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

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE

does not display a currently valid OMB control number.

DESIRED SERVICING CONTRACTOR SHOWN BELOW.

PRIVACY ACT STATEMENT

This statement informs you of the purpose for collecting personal information required by the TRICARE Young Adult Program and how it will be used.

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care, 32 CFR Part 199, Civilian Health and Medical Program of the Uniformed Serivces

(CHAMPUS); DoD Instruction 1341.2, Defense Enrollment Eligibility Reporting System (DEERS) Procedures; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To collect the information necessary to process your request for coverage, to terminate coverage, or to change your provider.

ROUTINE USE(S): Any protected health information governed by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD by DoD

6025.18-R, may disclosed as permitted under those provisions, which includes for treatment, payment, and healthcare operations. In addition, your records

may be disclosed to the Department of Health and Human Services for use in reports and Medicare determinations. Your records may be disclosed to

Federal agencies, and state, local and territorial governments, in order to collect debts and overpayments, to determine whether beneficiaries are eligible for,

or enrolled in, other government or private health insurance plans, and to stop fraud, waste and abuse. Your records may be disclosed outside of DoD to

support research concerning the health and wellbeing of TRICARE beneficiaries. Your records may also be used and disclosed in accordance with 5

U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD "Blanket Routine Uses" published at

DISCLOSURE: Voluntary. However, failure to provide all requested information may result in denial of your request to enroll in or change your TRICARE

Young Adult health plan coverage.

TRICARE YOUNG ADULT PROGRAM

The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program that allows former dependents to purchase

TRICARE health care plan coverage if qualified. Coverage is extended from age 21 (age 23 if previously enrolled in a full-time course of study at an

institution of higher learning) until reaching age 26 for unmarried dependents that are not eligible for medical coverage from employer-sponsored medical

coverage as a result of their employment.

General eligibility requirements are shown below.

Sponsor

TRICARE

Uniformed

TRICARE

Status

Prime (1)

Prime Remote

Standard

Services Family

Overseas Prime

Overseas

(1)

Health Plan (1)

(1)

Remote (1)

Standard

Active Duty

Yes

Retired

Yes

Selected Reserve

Yes

(2)

Retired Reserve

Yes

(2)

(1) To purchase this coverage, it must be offered in your geographic area and you must meet all other eligibility criteria.

(2) If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be

enrolled in TRICARE Reserve Select or TRICARE Retired Reserve as applicable for you to be eligible to purchase TYA coverage.

For specific information on eligibility, coverage, costs, claims submission, go to:

APPLICATION OPTIONS

ONLINE:

You may electronically complete, submit and print a copy of your enrollment, disenrollment, transfer to another TYA plan, or request a change in an assigned

Primary Care Manager (PCM) by logging into the Beneficiary Web Enrollment (BWE) website at https:// The BWE website is not

available to beneficiaries in overseas areas.

MAILING THE FORM:

For manual enrollment, disenrollment, or PCM changes in a TRICARE Young Adult plan, complete and submit the form to the address below.

1. Forms may be mailed to the contractor identified below or, with the exception of USFHP applications, taken to a TRICARE Service Center (TSC). Call

your Contractor to determine when your new or transferred enrollment will begin.

Health Net Federal Services, LLC

1-877-TRICARE (1-877-874-2273)

2. For enrollment assistance, please call

3. For additional information on TRICARE, visit the TRICARE website at , the Contractor's website at

or your local TRICARE Service Center (TSC).

(TMA BE&SDs/Contractors will add servicing contractor information. Include name, mailing address and web address of contractor, and enrollment fees.)