DD Form 2876, TRICARE Prime Enrollment Application and PCM

TRICARE PRIME ENROLLMENT APPLICATION AND
PCM CHANGE FORM
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
Form Approved
OMB No. 0720-0008
Expires Jan 31, 2007
AGENCY DISCLOSURE NOTICE
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, Executive Services and Communications Directorate
(0720-0008). 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 does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR APPLICATION TO THE ABOVE
ORGANIZATION.
SEND YOUR APPLICATION TO THE ADDRESS SHOWN ON THE
APPLICATION INSTRUCTION SHEET.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 552a, 10 U.S.C. 1079 and 1086, 58 FR 45318, 65 FR 30966,
May15, 2000.
PRINCIPAL PURPOSE(S): To evaluate eligibility for medical care provided by civilian
sources to Military Health Services System beneficiaries applying for coverage under the
TRICARE Program (32 CFR 199.17).
ROUTINE USE(S): Information from application forms and related documents may be given
to the Department of Health and Human Services, and/or the Department of Transportation
consistent with their statutory administrative responsibilities under TRICARE; to the
Department of Justice for representation of the Secretary of Defense in civil actions.
Appropriate disclosures may be made to other Federal, State, local, and foreign
government agencies, private business entities, and individual providers of care, on matters
relating to entitlement, fraud, program abuse, program integrity, and civil and criminal
litigation related to the operation of the TRICARE Program.
DISCLOSURE: Voluntary; however, failure to provide information will result in the denial of
enrollment.
DD FORM 2876, MAR 2004
Page 1 of 8 Pages
TRICARE PRIME ENROLLMENT APPLICATION AND PCM CHANGE FORM
This form is for the following:
- Eligible beneficiaries who want to enroll in TRICARE Prime, TRICARE Prime Remote (TPR),
or US Family Health Plan.
- Portability transfers to a new region for the TRICARE program listed above.
- Address changes within the same region for the TRICARE program listed above.
- Primary Care Manager (PCM) changes as follows: Within the same Military Treatment
Facility (MTF)/Clinic, to an MTF/Clinic, or to a civilian PCM.
Review the eligible categories (1 through 5) below to determine the application sections you
must complete.
ELIGIBLE CATEGORIES
1. Active Duty Members,
Reserve Component
Members called or ordered
to active duty for 30 days
or more.
2. Active Duty Family
Members (ADFMs) and
Survivors of Active Duty
(first three years in
survivor status).
3. Active Duty Family
Members of Reserve
Component Members
called or ordered to active
duty for 31 days or more.
Must be eligible in DEERS.
4. Retirees, retiree family members,
survivors, and eligible former
spouses under 65 years of age
who reside within the 50 United
States or the District of
Columbia. This excludes
beneficiaries over the age of 65
who are eligible for TRICARE
Prime.
5. ADFMs, Retirees, retired
family members, survivors
and eligible former spouses
65 years or older and
entitled to Medicare Part
A. (Applicable only to US
Family Health Plan.)
DD FORM 2876, MAR 2004
SECTION
I
Sponsor
Information
SECTION
II
Enrolling
Family
Members
SECTION
III
Other
Health
Insurance
SECTION
IV
Reason
for PCM
Change
SECTION
V
Signature
X
Complete
if
changing
PCM
X
X
Complete
if
changing
PCM
X
X
Complete
if
changing
PCM
X
X
Complete
if
changing
PCM
X
Complete
if
changing
PCM
X
X
X
X
X
X
X
SECTION
VI
Enrollment
Fee
Payment
X
X
(Must
include
required
payment)
X
X
(If not
enrolled in
Medicare
Part B)
Page 2 of 8 Pages
GENERAL INSTRUCTIONS
1. TRICARE Prime - Active duty service members are required to enroll in Prime. Active
duty family members, retirees and their family members are encouraged, but not required,
to enroll in Prime.
2. TRICARE Prime Remote (TPR) is a program for active duty service members and their
family members when the sponsor lives and works over 50 miles or one hour drive from a
Military Treatment Facility (MTF) and the family member lives with the sponsor.
3. Families with more than three members need multiple copies of page 6.
4. Print all information in ink. Make sure the information is complete and accurate.
5. Ensure personal and family information matches information in the Defense Enrollment
Eligibility Reporting System (DEERS). To check your DEERS information, call the Defense
Manpower Data Center (DMDC) Support Office at 1-800-538-9552 and refer to your name
as printed on your military ID card.
If you are an unremarried former spouse, please remember to use your personal SSN as the
sponsor number.
6. There are two address fields for the sponsor and each family member. The Residence
address block should be completed if it is known. If you haven't established a residence at
the time you are completing this form, insert "To be determined." in the Residence address
block and complete the Mailing address block. The Mailing address block is only to be
completed if mail is to be sent to an address other than the Residence address. If the
Mailing address block is blank, all mail will be sent to the Residence address. The
addresses and telephone numbers you include on this form will update DEERS.
It is very important that you update your personal information in DEERS whenever your
residence address, mailing address, telephone number or Medicare status changes. Please
see instruction 5 above.
7. Sign and date the application (Section VI).
8. Please keep a copy of the completed TRICARE Prime Application/PCM Change Form for
your records.
Enrollment in TRICARE Prime requires that all services, except for emergencies, must be
coordinated through the PCM. If not, the beneficiary will be responsible for payment of
charges in accordance with the Point-of-Service (POS) option as described in the TRICARE
Beneficiary Handbook.
DD FORM 2876, MAR 2004
Page 3 of 8 Pages
GENERAL INSTRUCTIONS (Continued)
9. US Family Health Plan is a TRICARE Prime enrollment option for eligible individuals and
families who live in seven specific parts of the country: Seattle, Washington; Cleveland,
Ohio; Portland, Maine; Brighton, Massachusetts; Staten Island, New York; Baltimore,
Maryland; and Houston, Texas. The primary difference between other TRICARE options
and the US Family Health Plan is that US Family Health Plan may be used by uniformed
service retirees and their eligible family members who are age 65 or older.
10. For enrollment or PCM changes in the US Family Health Plan, submit the completed
Application/PCM Change Form to the US Family Health Plan address listed below. For
questions regarding enrollment/PCM changes in the US Family Health Plan, contact the US
Family Health Plan member services at:
ME & NH
USFHP at Martin's Point
Attn: Enrollment Dept.
PO Box 9746
Portland, ME 04104-5040
1-888-241-4556
MD, DC & Surrounding Area
USFHP at Johns Hopkins
Enrollment Office
PO Box 17489
Baltimore, MD 21203-7489
1-800-808-7347
MA & RI
US Family Health Plan
Attn: Enrollment Dept.
PO Box 9203
Waltham, MA 02454-9203
1-800-818-8589
NY & NJ
US Family Health Plan
St. Vincent Catholic Med Ctr.
75 Vanderbilt Avenue
Staten Island, NY 10304
1-800-241-4848
MAILING INSTRUCTIONS
1. Submit the completed Application/PCM Change Form to the address below. For
enrollment or PCM changes in the US Family Health Plan please see instruction 10 above.
Health Net Federal Services, Inc.
PO Box 870143
Surfside Beach, SC 29587-9743
Applications can be mailed to the contractor identified above or dropped off at a TRICARE
Service Center (TSC). Contact the local TSC in person or call the telephone number listed
below in instruction 3 to determine when your new or transferred enrollment will begin.
2. For additional information on TRICARE, contact the local TRICARE Service Center (TSC)
or visit the TMA website at www.tricare.osd.mil.
3. For enrollment assistance, please call Health Net Federal Services, Inc.
at 1-877-TRICARE (1-877-874-2273).
PAY INSTRUCTIONS
1. If you have elected monthly allotment from retired pay as the payment method for your
TRICARE Prime enrollment fees, you must complete an allotment authorization letter
provided. If you select this type of payment, you must make the first quarterly payment by
check at the time of application.
2. If you elected electronic funds transfer (EFT) as the payment method for your TRICARE
Prime enrollment fees, ensure you provide your banking information in Section VI, Part B of
the enrollment application form. If you select this type of payment, you must make the
first quarterly payment by check at the time of application.
3. If you elected credit card as the method for your TRICARE Prime enrollment, ensure you
provide your credit card information in Section VI, Part C of the enrollment application
form. If you select this type of payment, these payments are made either quarterly or
annually.
DD FORM 2876, MAR 2004
Page 4 of 8 Pages
TRICARE PRIME ENROLLMENT APPLICATION AND
PCM CHANGE FORM
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
X
one:
Prime
Enrollment
Prime Remote
Enrollment
US Family Health
Plan Enrollment
PCM
Change
1. SPONSOR SOCIAL SECURITY NUMBER (SSN)
2. SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
3. SPONSOR DATE OF BIRTH (YYYYMMDD)
4. SPONSOR IS:
(X one)
Active Duty
Retired
Deceased
Former Spouse
(Go to Section II.)
5. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
6. MAILING ADDRESS (If different from residence address)
b. WORK
7. SPONSOR TELEPHONE NUMBERS a. HOME
(Include Area Code)
8. CITY AND COUNTRY OF MILITARY ASSIGNMENT (OCONUS only)
9. MEMBER'S UNIT AND UNIT IDENTIFICATION CODE (UIC) (If known)
10. ZIP CODE OF WORK ADDRESS
11. E-MAIL ADDRESS
12. SPONSOR'S
ACTION (X one)
New Enrollment
PCM Change
None
13. SPONSOR PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your
preference depends upon availability and local Military Treatment Facility (MTF)
policy. Contact your TRICARE Service Center, preferred MTF, or US Family Health
Plan Member Services for availability of PCMs.) (Complete all that apply.)
1st CHOICE
a. PCM NAME
MTF/CLINIC
2nd CHOICE
(If known)
b. PCM
SPECIALTY
No Preference
Family/General
Practice
Flight Medicine
c. PREFERRED
PCM GENDER
No Preference
Male
DD FORM 2876. MAR 2004
Internal Medicine
ORIGINAL: DETACH AND MAIL THIS COPY.
Female
Page 5 of 8 Pages
SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
b. DATE OF BIRTH (YYYYMMDD)
c. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
Same as
Sponsor
d. MAILING ADDRESS (If different from residence address)
Same as
Sponsor
e. RELATIONSHIP TO SPONSOR
Spouse
Former Spouse
Child
(1) HOME
(2) WORK
f. TELEPHONE NUMBERS
(Include Area Code)
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends
upon availability and local MTF policy. Contact your TRICARE Service Center,
preferred MTF or US Family Health Plan Member service for availability of PCMs.)
(Complete all that apply.)
1st CHOICE
(1) PCM NAME
Same as Sponsor
MTF/CLINIC
2nd CHOICE
(If known)
Same as Sponsor
No Preference
Flight Medicine
Pediatrics
(2) PCM
Family/General
SPECIALTY
Internal Medicine
Practice
(3) PREFERRED
Male
No Preference
Female
PCM GENDER
a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
b. DATE OF BIRTH (YYYYMMDD)
c. RESIDENCE ADDRESS (Street/P.O. Box, Apartment No., City, State, ZIP Code)
Same as
Sponsor
d. MAILING ADDRESS (If different from residence address)
Same as
Sponsor
e. RELATIONSHIP TO SPONSOR
Spouse
Former Spouse
Child
(1) HOME
(2) WORK
f. TELEPHONE NUMBERS
(Include Area Code)
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Honoring your preferences depends
upon availability and local MTF policy. Contact your TRICARE Service Center,
preferred MTF or US Family Health Plan Member service for availability of PCMs.)
(Complete all that apply.)
1st CHOICE
(1) PCM NAME
Same as Sponsor
MTF/CLINIC 2nd CHOICE
(If known)
Same as Sponsor
No Preference
Flight Medicine
Pediatrics
(2) PCM
Family/General
SPECIALTY
Internal Medicine
Practice
(3) PREFERRED
No Preference
Male
Female
PCM GENDER
Page 6 of 8 Pages
DD FORM 2876, MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
1. IS THE RETIREE OR ARE ANY RETIREE FAMILY MEMBERS ELIGIBLE FOR
MEDICARE BASED ON DISABILITY OR END STAGE RENAL DISEASE?
Yes
No
If Yes, provide a copy of the Medicare card for each family member that is under the age
of 65 and entitled to Medicare.
2. ARE ANY ENROLLING FAMILY MEMBERS OR IS THE RETIREE
Yes
CURRENTLY COVERED BY OTHER HEALTH INSURANCE (not a TRICARE
No
Supplement)?
If Yes, provide the name of the other health insurance and the insurance identification
number:
REASON FOR CHANGE (X one per affected family member)
Name
Other (Explain)
Move
Name
Move
Other (Explain)
Name
Move
Other (Explain)
Name
Move
Other (Explain)
Please read and sign only if you are outside the service area.
Your enrollment application indicates that your current address is outside the service
area. You may travel to a location where there is a provider network and enroll at that
location. However, since you live outside the service area, by signing below, you
indicate that your travel time to the network of primary care delivery sites may exceed
30 minutes from your home to the delivery site and your travel time for specialty care
may exceed one hour.
SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL
DATE SIGNED
GUARDIAN OF BENEFICIARY
(YYYYMMDD)
I understand that it is my responsibility to comply with all TRICARE Prime
procedures. By signing the 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.
SIGNATURE OF SPONSOR, SPOUSE, OR OTHER LEGAL
DATE SIGNED
GUARDIAN OF BENEFICIARY
(YYYYMMDD)
DD FORM 2876, MAR 2004
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 7 of 8 Pages
SPONSOR SOCIAL SECURITY NUMBER
SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)
SECTION VII - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former
spouses.
1. Retired beneficiaries and retiree family members entitled to Medicare Part A and Medicare
Part B must be enrolled in Medicare Part B to be eligible for enrollment in TRICARE prime.
TRICARE enrollment fees are waived for these retirees and retiree family members if they
provide a copy of their Medicare card as proof of entitlement to Medicare Part A and B and
DEERS reflects their entitlement to Medicare Part A and B.
2. Explain all split enrollments (retiree family enrollment in more than one TRICARE Region) on
a separate sheet of paper.
1. PAYMENT
FEE
MONTHLY
QUARTERLY
ANNUAL
OPTIONS
2. PLAN
Single
$19.17
Single
$57.50
Single
$230.00
SELECTION
Family
$38.34
Family
$115.00
Family
$460.00
(X one)
a. Allotment From
a. Check/Cashiers
a. Check/Cashiers
Retired
Pay
Check/Money
Check/Money
3. PAYMENT
(Complete A below)
Order*
Order*
METHOD
b.
Electronic
Funds
b.
VISA
or
Master
b.
VISA
or Master
(X one)
Transfer (Complete
Card (Complete
Card (Complete
B below)
C below)
C below)
If you have elected a monthly payment option (Allotment or Electronic Funds Transfer) please
see Pay Instructions on Page 4 for further details regarding establishing monthly payments.
If you have elected Monthly Allotment or Electronic Funds Transfer, the first quarterly payment
is due at the time of application.
NOTE: Quarterly and annual bills will be sent on a quarterly and annual basis, respectively.
Monthly bills will not be sent.
*Make check payable to Health Net Federal Services
A
choose to have my enrollment fees paid by
I,
monthly allotment from my Uniformed Services
(Signature of sponsor)
retired pay.
NOTE: Only retired Uniformed Services members may establish an allotment from their retired
pay. Follow instructions on Premium Allotment Authorization letter and submit as directed.
B
I,
choose to have my enrollment fees paid by
electronic funds transfer.
(Signature of account holder)
(1) NAME AND ADDRESS OF FINANCIAL INSTITUTION
(2)
(3)
(4)
(5)
(6)
C
TELEPHONE NUMBER OF FINANCIAL INSTITUTION (Include Area Code)
Savings
Checking (Attach voided check)
ACCOUNT INFORMATION (X)
ACCOUNT NUMBER
BANK OR ABA ROUTING NUMBER
NAME ON ACCOUNT
choose to have my initial enrollment fees billed to
I,
my credit card. (Annual and Quarterly initial
(Signature of card holder)
payments only)
(1) NAME ON CREDIT CARD
(2) CREDIT CARD NUMBER AND EXPIRATION DATE (MMYY)
(3) TYPE OF CARD (X)
DD FORM 2876, MAR 2004
VISA
Master Card
ORIGINAL: DETACH AND MAIL THIS COPY.
Page 8 of 8 Pages