DD Form 2877 TRICARE Prime Disenrollment Applicaation

TRICARE PRIME DISENROLLMENT REQUEST

Form Approved
OMB No. 0720-0008

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 5 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 REQUEST TO THE ABOVE ORGANIZATION.
SEND YOUR REQUEST TO THE ADDRESS SHOWN IN THE INSTRUCTIONS.
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 disenroll from TRICARE Prime, TRICARE Prime Remote or the Uniformed Services Family Health
Plan as requested by the enrollee.
ROUTINE USE(S): Information from disenrollment application 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 continued enrollment and responsibility for payment
of applicable enrollment fee.

NEEDS DD 67

This form is for eligible beneficiaries whose enrollment in TRICARE Prime, TRICARE Prime Remote, or US Family
Health Plan is voluntary. Do not use this form if transferring enrollment to another region. Contact the
contractor in your new region to request an enrollment form.
GENERAL INSTRUCTIONS
1. For TRICARE Prime and TRICARE Prime Remote disenrollments, submit your completed disenrollment
request to the TRICARE contractor in your region or the TRICARE Service Center. For US Family Health Plan, see
instruction 2 below.

2. For US Family Health Plan disenrollments, submit your completed disenrollment request to the US Family
Health Plan facility where you are currently enrolled. For information on US Family Health Plan, visit the US Family
Health Plan website at www.usfhp.org, or please call
3. Families with more than six members need multiple copies of page 2.
4. Print all information in blue or black ink. Make sure the applicable information is complete and accurate.
5. Make sure all personal and family 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.
6. Sign and date the request (Section III).
NOTE: For some enrollees, you may incur a 12 month lock-out from TRICARE Prime. You may not be allowed
to re-enroll in TRICARE Prime for 12 months from the date of the disenrollment. This one-year period does
not apply to any dependent whose sponsor is in the grade of E-1 to E-4.
7. Please keep a copy of the completed request for your records. If faxed, please maintain a confirmation of fax.
8. For information on TRICARE, contact the local TRICARE Service Center (TSC) or visit the TRICARE website at
www.tricare.mil, or call 1-800-TRICARE or 1-800-874-2273.
DD FORM 2877, 20100128 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages
Adobe Professional 8.0

TRICARE PRIME DISENROLLMENT REQUEST
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)

SECTION I - SPONSOR INFORMATION (Must be completed on all requests)
1. SPONSOR SOCIAL SECURITY
NUMBER (SSN)

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

3. SPONSOR DATE OF BIRTH
(YYYYMMDD)

(Must match DEERS)

SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT
(Print extra copies of this page if more than 6 family members disenrolling)
(Number)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

b. DATE OF BIRTH (YYYYMMDD)

c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

NEEDS DD 67
e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

(Number)

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

(

)

(

)

b. DATE OF BIRTH (YYYYMMDD)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

(Number)

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

(

)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

(

)

b. DATE OF BIRTH (YYYYMMDD)

c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

DD FORM 2877, 20100128 DRAFT

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

(

)

(

)
Page 2 of 3 Pages

SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT (Continued)
(Number)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

b. DATE OF BIRTH (YYYYMMDD)

c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

NEEDS DD 67
e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

(Number)

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

(

)

(

)

b. DATE OF BIRTH (YYYYMMDD)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

c. RELATIONSHIP TO SPONSOR
Spouse
Former Spouse
Child
Self
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

(Number)

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

(

)

a. NAME (Last, First, Middle Initial) (Must match DEERS)

(

)

b. DATE OF BIRTH (YYYYMMDD)

c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT (X one) You may be subject to a 12-month lockout.
Other Voluntary Disenrollment (Explain)
Moved
Other Health Insurance

e. REQUESTED DISENROLLMENT DATE (YYYYMMDD)
(If different from above. Must not be more than 30 days in the
future.)

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

(

)

(

)

SECTION III - SIGNATURE
By signing this 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. I understand that by voluntarily disenrolling from TRICARE
Prime, TRICARE Prime Remote or US Family Health Plan, prior to the annual renewal, that I will not be allowed to
reenroll in TRICARE Prime, TRICARE Prime Remote, or US Family Health Plan for the 12 month period following my
disenrollment. (E-1 through E-4 exempt from lockout period).
SIGNATURE

DD FORM 2877, 20100128 DRAFT

DATE SIGNED

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