Form DD Form 2876 DD Form 2876 TRICARE Prime Enrollment Application and PCM Change Form

TRICARE PRIME ENROLLMENT APPLICATION AND
PRIMARY CARE MANAGER (PCM) CHANGE FORM

OMB No. 0720-0008
OMB approval expires

(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (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, 71 FR 15705, March 29, 2006.
PRINCIPAL PURPOSE(S): To apply for enrollment in TRICARE Prime, TRICARE Prime Remote or the Uniformed Services Family
Health Plan as requested by the enrollee.
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 Homeland Security 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 may result in the denial of enrollment.

This form is for the following:
- To allow eligible beneficiaries to apply for enrollment in TRICARE Prime, TRICARE Prime Remote (TPR), or US
Family Health Plan.
- Enrollees to change to a new region for the TRICARE programs listed above.
- Enrollees to update their personal contact information to include addresses, phone numbers, and email within the
same region for the TRICARE programs listed above.
Review the eligible categories (1 through 5) below to determine the application sections you must complete.
ELIGIBLE CATEGORIES

1. Active Duty Members, Guard and
Reserve Component Members
called or ordered to active duty for
more than 30 consecutive days.
2. Active Duty Family Members
(ADFMs) and Survivors of Active
Duty (in transitional survivor
status).

SECTION
I
Sponsor
Information

SECTION
II
Enrolling
Family
Members

SECTION
III
Other
Health
Insurance

4. Eligible retirees, their 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 includes beneficiaries 65
years and over who are NOT
eligible for Medicare Part A
on their record or their spouse's
record.
5. ADFMs, retirees, retired family
members, survivors and eligible
former spouses who are entitled
to Medicare Part A.

SECTION
V
Access
to Care
Waiver

SECTION
VI
Signature

X

Complete
if
changing
PCM*

X

X

X

X

Complete
if
changing
PCM*

X

X

X

X

Complete
if
changing
PCM*

X

X

Complete
if
changing
PCM*

X

Complete
if
changing
PCM*

D R A F T

3. Family Members of Guard and

Reserve called or ordered to active
duty for more than 30 consecutive
days may be eligible in DEERS.

SECTION
IV
Reason
for PCM
Change

X

X

X

X

SECTION
VII
Enrollment
Fee
Payment

X
X

(Must
include
required
payment)

X
X

(If not
enrolled in
Medicare
Part B)

* Complete if selected PCM is greater than 30 minutes from residence address.

DD FORM 2876, 20100128 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 7 Pages
Adobe Professional 8.0

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. Please note that enrollment
is not automatic.
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. Note: If residing in a Prime Service area, family members wishing to enroll must
choose Prime and not TPR ADFM.
3. US Family Health Plan is a TRICARE Prime enrollment option for eligible individuals and families who live in six
specific parts of the country: Seattle, Washington; Portland, Maine; Boston, 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.

D R A F T

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:

4. If enrolling more than three family members, fill out additional copies of Page 5.
5. Print in blue or black ink; make sure all available information is complete, accurate and legible.
6. Make sure all personal information matches that in the Defense Enrollment Eligibility Reporting System
(DEERS). To check your DEERS information, call the Support Office at 1-800-538-9552 or log on to
http://www.dmdc.gov and refer to your name as printed on your military ID card.
7. If you are an unremarried former spouse, make sure you show in DEERS under your own Social Security
Number and use your own SSN as the "Sponsor Social Security Number" on the enrollment form (block 1).
8. If you become Medicare-eligible, for any reason, make sure your Medicare Part A and B status is correctly
reflected in DEERS (Part B is required for all TRICARE beneficiaries, other than active duty family members.
Though Part B is not required for US Family Health Plan enrollees, the Department of Defense highly encourages
enrollment in Part B when first eligible to avoid potential Medicare Part B surcharges for enrollment.)
9. Sign and date the application (Section VI).
10. 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, 20100128 DRAFT

Page 2 of 7 Pages

MAILING INSTRUCTIONS
1. For enrollment or PCM changes in TRICARE/TRICARE Prime Remote, 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 3 above.)

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.mil.

D R A F T

3. For enrollment assistance, please call
at

PAY INSTRUCTIONS
1. If you have elected monthly allotment from retired pay as the payment method for your TRICARE Prime
enrollment fees, you must also complete and submit the allotment authorization letter with your application. If you
select this type of payment, you must make the first quarterly payment by check, credit card or money order 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 VII, Part B of the enrollment application form. If you select
this type of payment, you must make the first quarterly payment by check, credit card or money order at the time of
application.
3. If you elected credit card as the method for your initial TRICARE Prime enrollment, ensure you provide your
credit card information in Section VII, Part C of the enrollment application form. These payments are made either
quarterly or annually.

DD FORM 2876, 20100128 DRAFT

Page 3 of 7 Pages

TRICARE PRIME ENROLLMENT APPLICATION AND
PRIMARY CARE MANAGER (PCM) CHANGE FORM
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)

SECTION I - SPONSOR INFORMATION
X one:
Prime
Enrollment

US Family
Health Plan
Enrollment

Prime Remote
Enrollment

Transfer
Enrollment

PCM Change

Split
Enrollment

1. SPONSOR IS: (X one)
Active Duty

Retired

Deceased (Go to Section II.)

2. SPONSOR SOCIAL SECURITY
NUMBER (SSN)

Former Spouse

3. SPONSOR NAME (Last, First, Middle Initial)

4. SPONSOR DATE OF BIRTH
(YYYYMMDD)

(Must match DEERS)

5. RESIDENCE ADDRESS
a. STREET

b. APARTMENT/
SUITE NO.

c. CITY

d. STATE e. ZIP CODE

c. CITY

d. STATE e. ZIP CODE

6. MAILING ADDRESS (If different from residence address)
a. STREET

b. APARTMENT/
SUITE NO.

D R A F T
7. SPONSOR TELEPHONE NUMBERS (Include Area Code)
a. HOME

(

b. WORK

)

(

8. CITY AND COUNTRY OF MILITARY ASSIGNMENT
(OCONUS only)

)
10. UNIT
11. ZIP CODE OF
IDENTIFICATION
WORK
CODE (UIC)
ADDRESS

9. MEMBER'S UNIT

12. E-MAIL ADDRESS

(If known)

13. SPONSOR PRIMARY CARE 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
MTF
a. PCM FULL NAME,
MTF/CLINIC
ADDRESS
(If known)

Other
2nd CHOICE
MTF
Other
No Preference

Flight Medicine

Family/General Practice

Internal Medicine

b. PCM SPECIALTY
c. PREFERRED PCM GENDER

DD FORM 2876, 20100128 DRAFT

No Preference

Male

ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.

Female
Page 4 of 7 Pages

SPONSOR SOCIAL SECURITY NUMBER SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)

SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE
(Use additional copies of this page to continue as necessary)
1.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. RESIDENCE ADDRESS
(1) STREET

b. DATE OF BIRTH (YYYYMMDD)

Same as Sponsor
(3) CITY

(4) STATE (5) ZIP CODE

d. MAILING ADDRESS (If different from residence address)
Same as Sponsor
(1) STREET
(2) APARTMENT/ (3) CITY
SUITE NO.

(4) STATE (5) ZIP CODE

e. RELATIONSHIP TO
SPONSOR
Spouse

Child

(2) APARTMENT/
SUITE NO.

f. TELEPHONE NUMBERS (Include Area Code) (If different from sponsor) g. E-MAIL ADDRESS
(1) HOME
(2) WORK

(

)

(

)

h. 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.)

(1) PCM
FULL NAME
MTF/CLINIC
ADDRESS

1st CHOICE
Same as
Sponsor
MTF
Other

D R A F T

2nd CHOICE
Same as
(If known)
Sponsor
MTF
Other
(2) PCM SPECIALTY
No Preference
Flight Medicine
Pediatrics
(3) PREFERRED PCM GENDER
No Preference
Male
2.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)

c. RESIDENCE ADDRESS
(1) STREET

Same as Sponsor
(2) APARTMENT/
SUITE NO.

Family/General Practice

Internal Medicine

Female

b. DATE OF BIRTH (YYYYMMDD)

(3) CITY

(4) STATE (5) ZIP CODE

d. MAILING ADDRESS (If different from residence address)
Same as Sponsor
(1) STREET
(2) APARTMENT/ (3) CITY
SUITE NO.

(4) STATE (5) ZIP CODE

e. RELATIONSHIP TO
SPONSOR
Spouse

Child

f. TELEPHONE NUMBERS (Include Area Code) (If different from
(1) HOME
(2) WORK

(

)

(

g. E-MAIL ADDRESS

)

h. 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.)

(1) PCM
FULL NAME
MTF/CLINIC
ADDRESS

1st CHOICE
Same as
Sponsor
MTF
Other

2nd CHOICE
Same as
(If known)
Sponsor
MTF
Other
(2) PCM SPECIALTY
No Preference
(3) PREFERRED PCM GENDER

DD FORM 2876, 20100128 DRAFT

Flight Medicine
No Preference

Pediatrics

Family/General Practice

Male

Female

ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.

Internal Medicine
Page 5 of 7 Pages

SPONSOR SOCIAL SECURITY NUMBER SPONSOR NAME (Last, First, Middle Initial) (Must match DEERS)

SECTION III - OTHER HEALTH INSURANCE
1. ARE ANY ENROLLING FAMILY MEMBERS OR IS THE RETIREE CURRENTLY COVERED BY OTHER
HEALTH INSURANCE (not a TRICARE Supplement)?
If Yes, provide the name of the family member and other health insurance, policy number, effective dates, and a
copy of the other health insurance policy and their insurance card.

Yes
No

D R A F T
2. IS THE RETIREE OR ARE ANY RETIREE FAMILY MEMBERS UNDER AGE 65 AND ELIGIBLE FOR
MEDICARE BASED ON DISABILITY OR END STAGE RENAL DISEASE? If Yes, provide a copy of the
Medicare card for each family member that is under the age of 65 and entitled to Medicare.

Yes
No

SECTION IV - REASON FOR PCM CHANGE
2. REASON FOR CHANGE (X as applicable. If more than one family

1. NAME OF AFFECTED FAMILY MEMBER(S)

member and reason, specify.)

Dissatisfied

Permanent Change
of Station (PCS)

Relocation

Other (Use Section II to specify change of PCM specialty/
gender preference for more than one family member.)

SECTION V - ACCESS WAIVER
Please read and sign only if you are outside the service area.
By signing this application, you indicate your understanding and acceptance 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. Note: Certain restrictions may apply.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
LEGAL GUARDIAN OF BENEFICIARY

2. RELATIONSHIP TO
SPONSOR

3. DATE SIGNED(YYYYMMDD)

SECTION VI - SIGNATURE
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.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
LEGAL GUARDIAN OF BENEFICIARY

DD FORM 2876, 20100128 DRAFT

2. RELATIONSHIP TO
SPONSOR

3. DATE SIGNED(YYYYMMDD)

ORIGINAL: DETACH AND MAIL THIS COPY.
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Page 6 of 7 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.
Retired beneficiaries under age 65 and retiree family members entitled to Medicare Part A must be enrolled in Medicare Part B to
be eligible for enrollment in TRICARE prime. TRICARE enrollment fees are waived for individuals entitled to Medicare Part B, as
reflected in DEERS.
1. PAYMENT FEE
OPTIONS

MONTHLY
(See Note 1 below)

2. PLAN SELECTION

Single

$19.17

Single

$57.50

Single

$230.00

Family

$38.34

Family

$115.00

Family

$460.00

(X one)

3. PAYMENT
METHOD
(X one)

QUARTERLY
(See Note 2 below)

ANNUAL
(See Note 2 below)

a. Allotment From Retired Pay
(Complete A below)

a. Check/Cashiers Check/
Money Order
(See Note 3)

a. Check/Cashiers Check/
Money Order
(See Note 3)

b. Electronic Funds Transfer
(See Note 4)
(Complete B below)

b. VISA or Master Card
(Complete C below)

b. VISA or Master Card
(Complete C below)

Note 1: If you have elected a monthly payment option (Allotment or Electronic Funds Transfer) please see Pay Instructions on Page
3 for further details regarding establishing monthly payments.
If you have elected Monthly Allotment or Electronic Funds Transfer, the first quarterly payment (Single - $57.50/family - $115.00) is
due at the time of application.
Note 2: Quarterly and annual bills will be sent on a quarterly and annual basis, respectively. Monthly bills will not be sent.
Note 3: Make check payable to (Contractor's Name)
Note 4: Electronic Funds Transfer is for monthly payments only. Arrangement for electronic payments will be the responsibility
of the enrollee.

A - MONTHLY ALLOTMENT
I,

choose to have my enrollment fees paid by monthly allotment from my
(Signature of sponsor)
Uniformed Services retired pay.
NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The additional Allotment
Authorization Letter must be submitted with the application. Follow instructions on Premium Allotment Authorization letter and submit
as directed.

B - ELECTRONIC FUNDS TRANSFER
I,

choose to have my enrollment fees paid by electronic funds transfer.

(Signature of account holder)
(1) NAME AND ADDRESS OF FINANCIAL INSTITUTION

D R A F T
(4) ACCOUNT NUMBER

(3) ACCOUNT INFORMATION (X)
Savings

(2) TELEPHONE NUMBER OF
FINANCIAL INSTITUTION
(Include Area Code)

(

)

(5) BANK OR ABA ROUTING NO.

Checking (Attach voided check)

(6) NAME ON ACCOUNT

C - CREDIT CARD
I,
(Signature of card holder)

choose to have my initial enrollment fees billed to my credit card.
(Annual and Quarterly initial payments only)

NOTE: This is not a reoccurring payment. You are responsible for all subsequent fees when paying with a credit card.
(1) NAME ON CREDIT CARD

(2) CREDIT CARD NUMBER

(3) EXPIRATION DATE
(MMYY)

DD FORM 2876, 20100128 DRAFT

ORIGINAL: DETACH AND MAIL THIS COPY.
CARBON COPY: RETAIN FOR YOUR RECORDS.

Reset

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