Form Delta Dental Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Application

TRICARE Retiree Dental Program

OMB No. 0720-0015
Exp: xx-xx-xx

Enrollment application
Please PRINT CLEARLY and complete all applicable sections.

Delta Dental Use Only
Spl Att/Stat:
Eff Date:
Client/Sub:
Amt:
Auth/Ck No:

PRIVACY ACT STATEMENT

This statement serves to inform you of the purpose for collecting personal information required by the TRICARE Retiree Dental Program (TRDP) and
how it will be used.
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. 1781, Medical Care for Survivors and Dependents of Certain Veterans; 32 CFR
199.22, TRICARE Retiree Dental Program (TRDP); and E.O. 9397 (SSN), as amended.
PURPOSE: To obtain information from an individual for records pertaining to eligibility, claims processing, quality of care review, customer service
enhancement, and payment related to the TRICARE Retiree Dental Program.
ROUTINE USES: Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health Insurance
Portability and Accountability Act (HIPAA) Privacy and Security Rules, as implemented by DoD 6025.18-R, the DoD Health Information Privacy
Regulation, http://dpclo.defense.gov/privacy/SORNS/blanket_routine_uses.html. In addition to those disclosures generally permitted under 5
U.S.C. 552a(b) of the Privacy Act of 1974, the DoD “Blanket Routine Uses” under 5 U.S.C. 552a(b)(3) apply to this collection. Information from this
system may be shared with federal, state, local, or foreign government agencies, and with private business entities, including individual providers
of care, on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review,
program integrity, third-party liability, coordination of benefits, and civil or criminal litigation.
DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed, but absence of the requested information may
result in the denial of benefits.

A Applicant
Retiree’s Social Security Number


Retiree
 Unremarried Surviving Spouse

Surviving Child(ren)

Family Member(s) Only. Written documentation required—see Guidelines for criteria.

XXX-XX-XXXX
Applicant’s Date of Birth
MM/DD/YYY

Last Name First Name MI

Sex

Branch of Service

M/F

Street Address
Street Address
City, State (or if overseas, province, county, etc.), ZIP/Foreign Postal Code, Country

Home Telephone Work Telephone

TRDP Welcome Packet delivery method (check one)
 YES, I prefer to access my Welcome Packet materials online. Please send instructions to me at the following e-mail address:
E-mail Address



NO, I prefer to receive my Welcome Packet materials through the standard mail (USPS) at the street address above.

B Family Members

If child is 21 or older

Please list only the eligible family members you wish to enroll in the TRDP.
FIRST, MI, LAST (if different)

SEX

BIRTH DATE

FULL-TIME
STUDENT

DISABLED

Spouse

M/F

MM/DD/YYYY

N/A

N/A

Child

M/F

MM/DD/YYYY

Y/N

Y/N

Child

M/F

MM/DD/YYYY

Y/N

Y/N

Child

M/F

MM/DD/YYYY

Y/N

Y/N

Child

M/F

MM/DD/YYYY

Y/N

Y/N

Child

M/F

MM/DD/YYYY

Y/N

Y/N

Child

M/F

MM/DD/YYYY

Y/N

Y/N

To avoid processing delays, be sure to complete, read and sign the back of this application.

C Premium Prepayment
TRICARE Retiree Dental Program premiums are collected automatically through Uniformed Services retired pay deduction. The
automatic deduction is directed by Title 10 of the United States Code, Section 1076c, and uses one of six discretionary allotments. If
retired pay is not available or is insufficient to allow the allotment amount, you will be billed directly.
Enrollment option (check one)
 Single Enrollment  Two-Person Enrollment



Family Enrollment (3 or more)

To determine your regional premium rate and prepayment amount, visit our website at trdp.org, or call our toll-free number,
888-838-8737. Prepayment of two months of premiums is necessary for enrollment. Any unused prepayment will be returned to the
enrollee during the third month of enrollment.
Two-month premium prepayment method (check one)
 Check/Money Order (made payable to the TRICARE Retiree Dental Program in U.S. dollars)
 Discover©/VISA©/MasterCard© (see Guidelines) X X X X - X X X X - X X X X - X X X X cvc/cvv X X X Exp. Date M M/ Y Y
BILLING ADDRESS (if different than mailing address)
Street Address
Street Address
City, State (or if overseas, province, county, etc.), ZIP/Foreign Postal Code, Country

D Enrollment Grace Period/Termination
Each new enrollee in the TRICARE Retiree Dental Program must fulfill an initial enrollment period of 12 consecutive months. This
initial enrollment period starts upon the coverage effective date. There is a grace period of 30 days from the coverage effective date in
which the enrollee may rescind the application without any further enrollment obligation, provided no covered services have been
used during that time period. To exercise the option to rescind, the enrollee must contact Delta Dental in writing within the 30day grace period. If the option to rescind the application within the 30-day grace period is not exercised, the enrollee must remain
enrolled in the program for the duration of the initial 12-month period with only limited opportunity for voluntary termination
during this time. An enrollment may be terminated involuntarily prior to the end of the 12-month time period due to loss of
eligibility. After the 12-month enrollment period, enrollment renewal will continue automatically on a month-to-month basis.

E

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 DoD/WHS/ESD Information Management Division, 4800 Mark
Center Drive, Suite 02G09, Alexandria, VA 22350-3100. 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 address. Return the completed application to the
following address: DELTA DENTAL OF CALIFORNIA, FEDERAL GOVERNMENT PROGRAMS, PO BOX 537008, SACRAMENTO, CA 958537008, UNITED STATES OF AMERICA.

F Authorization—This section must be signed and dated.
I have read the information contained on this application and choose to enroll in the TRICARE Retiree Dental Program.
I understand the benefit restrictions of the program as stated to me and/or explained in the materials provided with this
application. I further acknowledge my understanding of the following:
• Deposit of my prepayment does not guarantee coverage.
• My enrollment is subject to receipt of payment and verification of funds.
• My monthly premium payment will be automatically deducted from my retired pay, and I will be billed directly only if
retired pay is not available to me or is determined to be insufficient to allow the automatic monthly deduction.
• I must remain enrolled for 12 consecutive months and if I choose to continue my enrollment beyond the initial 12-month
period, my enrollment will continue on a month-to-month basis.
• This program does not discriminate, or have the effect of discriminating, against anyone on the basis of health status, age,
race, sex or sponsor rank.
• I certify under penalty of perjury that I, as well as any of my dependents covered under this program, meet the eligibility
requirements as identified in the “Eligibility” section of the marketing brochure included with this application or on the
TRDP web site.
• Notwithstanding this certification of eligibility, if I or any of my dependents do not meet the eligibility requirements of
this program, coverage under the program will be cancelled immediately and any premiums previously paid prior to the
effective date of cancellation of coverage will be retained by Delta Dental.
• Delta Dental may request military retirement documents from me to verify eligibility and I agree to provide them within
60 days of the request. I understand that by failing to provide the requested documents within the stated timeframe, any
dental claims submitted may be delayed or ultimately denied.

I hereby certify that the information contained on this application is true and complete.

X

Applicant Signature

Date

The development of this piece is supported by Department of Defense Contract No. H94002-07-C-0003. The TRDP is administered and underwritten by Delta Dental of California. 

MM042App 07/11