Form DD Form 2876 DD Form 2876 TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CAR

OMB No. 0720-0008
OMB approval expires

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

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 (0720-0008). 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 FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS
BELOW.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17; 32 CFR 199.17; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to enroll, disenroll, or change their provider in TRICARE
Prime, TRICARE Prime Remote, or the Uniformed Services Family Health Plan, as requested by the individual.
ROUTINE USE(S): 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. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as
amended, the DoD "Blanket Routine Uses" under 5 U.S.C. 552a(b)(3) apply to this collection. A complete listing of the routine uses
permitted under 5 U.S.C. 552a(b)(3) is published at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html. Collected
information may be shared with the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and other
Federal, State, local, or foreign government agencies, private business entities, including entities under contract with the Department of
Defense and 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; however, your failure to provide all the requested information may result in the denial of the request to enroll in,
transfer, or terminate your TRICARE Prime health plan coverage.
APPLICATION OPTIONS
ONLINE:
You may electronically complete, submit and print a copy of your enrollment, disenrollment or change online by logging into the Beneficiary
Web Enrollment (BWE) website at https://www.tricare.mil/bwe/. The BWE website is not available to beneficiaries in overseas areas.

D R A F T

MAILING THE FORM:
For manual enrollment, disenrollment, or Primary Care Manager (PCM) changes in TRICARE Prime, TRICARE Prime Remote or US Family
Health 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.
2. For enrollment assistance, please call [Contractor's Name]

at

[1-800-XXX-XXXX or FAX for OCONUS]

3. For additional information on TRICARE, visit the TRICARE website at www.tricare.mil, the Contractor's website at
[Contractor's Website]
or your local TRICARE Service Center (TSC).
(TMA BE&S/Contractors will add servicing contractor information. Include name, mailing address and web address of contractor, and enrollment fees.)

Uniformed Services Family Health Plan (USFHP)

[Region]
[US Family Health Plan]

[Street Address]
[City, State, 9-digit ZIP Code]
[1-800-XXX-XXXX]

DD FORM 2876, 20120816 DRAFT

REPLACES PREVIOUS EDITION AND DD FORM 2877, WHICH ARE OBSOLETE.

Page 1 of 5 Pages
Adobe Professional 8.0

SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED:
TRICARE Prime: Active duty service members (ADSM) are required to enroll in TRICARE Prime. Please note that enrollment
is not automatic. If eligible, you may be enrolled in TRICARE Prime Remote (TPR) or TRICARE Prime Remote for Active Duty
Family Members (TPRADFM).
TRICARE Overseas Program Prime: Dependents must be command sponsored and meet specific enrollment criteria of the
overseas area. If eligible, you may be enrolled in TRICARE Overseas Program Prime Remote. Retirees are not eligible for
TRICARE Overseas Program Prime.
Uniformed Services Family Health Plan (USFHP): Available in six locations. Submit the completed Enrollment Application to
the USFHP address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the
TRICARE website at www.tricare.mil/usfhp.

SECTION I - SPONSOR INFORMATION
1. SPONSOR'S NAME (Last, First, Middle Initial) (Must match DEERS)

2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
(XXX-XX-XXXX) or DoD BENEFITS NUMBER (DBN)
(XXXXXXXXX-XX)

3. SPONSOR IS: (X one)

Active Duty

Retired

Deceased (Go to Section II.)

4. SPONSOR'S TELEPHONE NUMBER (Include Area Code)
a. WORK:
b. RESIDENTIAL:

Unremarried Former Spouse

5. SPONSOR'S E-MAIL ADDRESS

(X box to receive TRICARE e-mails)

6. SPONSOR'S RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code, Country)

New

D R A F T
7. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)

8. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT

Same as residence

New

c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS

b. UNIT IDENTIFICATION CODE (UIC) (If known)

9. REQUESTED ACTION (X one)
None (go to Section II)

Enroll

Transfer Enrollment

PCM Change

Disenroll

Effective Date:
10. SPONSOR'S PRIMARY CARE PCM PREFERENCE (Please list your first and second choices below. 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 (non-active duty only) for availability of PCMs.)
a. 1st CHOICE

FULL NAME or MTF/CLINIC

MTF
Civilian
b. 2nd CHOICE

FULL NAME or MTF/CLINIC

MTF
Civilian
c. PCM SPECIALTY

No Preference

d. PREFERRED PCM GENDER

DD FORM 2876, 20120816 DRAFT

Family/General Practice
No Preference

Male

Internal Medicine

Flight Medicine

Female
Page 2 of 5 Pages

SPONSOR'S SSN/DBN:
SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE (Use additional copies of this page as necessary)
11.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
Enroll

c. REQUESTED ACTION:

d. RESIDENCE/MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)

Transfer Enrollment

b. DATE OF BIRTH (YYYYMMDD)
PCM Change

Disenroll

Effective Date:

Same as Sponsor
New

f. E-MAIL ADDRESS

e. TELEPHONE NUMBER (Include Area Code)
(1) WORK:
(2) RESIDENTIAL:

(X box to receive TRICARE e-mails)

g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Please list your first and second choices below. 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
service for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

h. PCM SPECIALTY

Family/General Practice

No Preference

i. PREFERRED PCM GENDER

No Preference

Internal Medicine

Male

Enroll

d. RESIDENCE/MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)

Transfer Enrollment

Flight Medicine

Female

12.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. REQUESTED ACTION:

Pediatrics

b. DATE OF BIRTH (YYYYMMDD)
PCM Change

Disenroll

Effective Date:

D R A F T

Same as Sponsor
New

f. E-MAIL ADDRESS
e. TELEPHONE NUMBER (Include Area Code)
(X box to receive TRICARE e-mails)
(1) WORK:
(2) RESIDENTIAL:
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Please list your first and second choices below. 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
service for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

h. PCM SPECIALTY

Family/General Practice

No Preference

i. PREFERRED PCM GENDER

No Preference

Internal Medicine

Male

Enroll

d. RESIDENCE/MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)

Transfer Enrollment

Flight Medicine

Female

13.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. REQUESTED ACTION:

Pediatrics

b. DATE OF BIRTH (YYYYMMDD)
PCM Change

Disenroll

Effective Date:

Same as Sponsor
New

f. E-MAIL ADDRESS
e. TELEPHONE NUMBER (Include Area Code)
(X box to receive TRICARE e-mails)
(1) WORK:
(2) RESIDENTIAL:
g. PRIMARY CARE MANAGER (PCM) PREFERENCE (Please list your first and second choices below. 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
service for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

FULL NAME or MTF/CLINIC

h. PCM SPECIALTY

No Preference

i. PREFERRED PCM GENDER

DD FORM 2876, 20120816 DRAFT

Family/General Practice
No Preference

Male

Internal Medicine

Pediatrics

Flight Medicine

Female
Page 3 of 5 Pages

SPONSOR'S SSN/DBN:

SECTION III - REASON FOR DISENROLLMENT OR PCM CHANGE
Name of Family Member:

Relocation

Dissatisfied with PCM

PCS

Other:

Name of Family Member:

Relocation

Dissatisfied with PCM

PCS

Other:

Name of Family Member:

Relocation

Dissatisfied with PCM

PCS

Other:

Name of Family Member:

Relocation

Dissatisfied with PCM

PCS

Other:

SECTION IV - OTHER HEALTH INSURANCE
PLEASE IDENTIFY IF ANYONE IS CURRENTLY COVERED BY OTHER HEALTH INSURANCE.
TRICARE Supplement (no other information is needed)
Medical Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

Dental Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

D R A F T

Policy Number:
Vision Insurance:

Policy Effective Date:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

Prescription Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:
SECTION V - ACCESS WAIVER AND SIGNATURE (REQUIRED)

I understand that if I selected a Primary Care Manager (PCM) by name, team or location (MTF or civilian), the TRICARE program will
enroll me with that PCM if capacity exists. If my selected or assigned PCM is greater than a 30 minute drive-time from my residence, or if
I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time
from my residence, and (2) this application constitutes my agreement to waive both the primary care and specialty care access standard
as applicable.
I understand that it is my responsibility to comply with all TRICARE Prime, TRICARE Overseas Program Prime, and/or USFHP policies
and procedures. By signing this form, I certify the information provided 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/or imprisonment under
applicable Federal law.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
LEGAL GUARDIAN OF BENEFICIARY

2. RELATIONSHIP TO SPONSOR

3. DATE SIGNED(YYYYMMDD)

ENROLLMENT NOTE: Initial enrollment effective dates are based primarily on the 20th of the month rule (applications received by the
20th of the month are effective the first day of the next month). You should confirm enrollment and PCM assignment before obtaining
routine medical care by calling your contractor. (Note: This section does not apply to TRICARE Overseas.)
DISENROLLMENT NOTE: For retirees and their family members, you may incur a 12 month lock-out from TRICARE Prime for failure to
pay enrollment fees. You may not be allowed to re-enroll in TRICARE Prime for 12 months from the date of the disenrollment.
PAYMENT OPTIONS: See Section VI on next page.

DD FORM 2876, 20120816 DRAFT

Page 4 of 5 Pages

SPONSOR'S SSN/DBN:
SECTION VI - PAYMENT OF TRICARE PRIME ENROLLMENT FEES
NOTE: This section is only for retirees, retiree family members, survivors and eligible former spouses.
Retired beneficiaries and retiree family members under age 65 who are entitled to Medicare Part A must be enrolled in Medicare Part
B to be eligible for enrollment in TRICARE prime. TRICARE Prime enrollment fees are waived for individuals enrolled in Medicare
Part A and Part B, as reflected in DEERS.
PAYMENT OPTIONS: See Sections A, B, and C below for elective payment options. Your initial enrollment application must include
payment for at least the first three (3) months of coverage. You may pay this amount either by credit card, money order or personal
check. Checks should be made payable to:
[Contractor's Name]
Note 1, Monthly Allotment: If you elect the Monthly Allotment payment option below, you must also complete and submit the
allotment authorization letter/form (available on each contractor's website) with your application. If you select the monthly payment
plan, you must make an initial three month payment by check, credit card or money order at the time of application. Monthly bills will
not be sent.

D R A F T

Note 2, Quarterly and Annual: Bills will be sent on a quarterly and annual basis for credit card payment. The payments can be
recurring as established by the enrolling contractor.
Note 3, Personal Check: Payment by check is limited to the initial three month payment for beneficiaries who elect allotment or EFT.
Note 4, Electronic Funds Transfer: EFT is for monthly payments only. Arrangement for electronic payments will be the
responsibility of the enrollee. The initial payment cannot be made electronically.
PAYMENT FEE, PLAN AND
METHOD OPTIONS (Some
options are location specific)

MONTHLY

QUARTERLY

ANNUAL

VISA or MasterCard

Allotment From Retired Pay

VISA or MasterCard

Electronic Funds Transfer
VISA or MasterCard

A - MONTHLY ALLOTMENT
I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay.
Individual $

Family $

(The current rates are at www.tricare.mil/costs)

Signature
NOTES: Only retired Uniformed Services members may establish an allotment from their retired pay. An Allotment form is required and must be
submitted with the application. See Note 1 above.

B - ELECTRONIC FUNDS TRANSFER
ELECTRONIC FUNDS TRANSFER
Individual $

AUTOMATIC MONTHLY PAYMENTS
Family $

Checking (attach voided check)

Savings

(The current rates are at www.tricare.mil/costs)

Name and Address of Financial Institution
Name on Account

Telephone Number of Financial Institution

Account Number

ABA Routing Number

Signature

C - CREDIT CARD
VISA/MASTERCARD MONTHLY, QUARTERLY, OR ANNUAL PAYMENTS
Individual $
VISA/MASTERCARD:

Family $

(The current rates are at www.tricare.mil/costs)

Number

Exp. Date (MM/YYYY)

Security Code (3-digit number on reverse side of card)
Name of Cardholder
Cardholder Signature

DD FORM 2876, 20120816 DRAFT

Reset

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