2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Car

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OMB No. 0720-0008
OMB approval expires
20220831

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, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@ mail.mil. 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.

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://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. 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.
APPLICABLE SORN: EDHA07 - Military Health Information System - http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wideSORN-Article-View/Article/570672/edha-07/
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

DRAFT

(1) ONLINE:
You may request to enroll, disenroll or change your primary care manager (PCM) by logging into the Beneficiary Web Enrollment website
at https://milconnect.dmdc.osd.mil
(2) TELEPHONE:
You may enroll, disenroll, or change your PCM by calling your Regional Contractor or US Family Health Plan (USFHP) at the toll-free
numbers on this page.
(3) ENROLLMENT FORM:
You may also enroll, disenroll, or change your PCM by completing and submitting the form to your Regional Contractor or USFHP at the
address or fax number below.
(4) NOTES:
You will be notified of your enrollment or PCM change via email or postcard. You can then log into milConnect at: https://
www.dmdc.osd.mil/milconnect/ to view specific information. For additional information on TRICARE, visit the TRICARE website at
www.tricare.mil or the Regional Contractor's website at: www.humanamilitary.com

REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS:
Region: EAST REGION
Address: Humana Military, Attn: PNC Bank, PO Box 105838, Atlanta GA 30348-5838
Toll-Free Number: 1-800-444-5445
Fax Number: 1-866-836-9535

UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP):
Address: (1) Martin's Point, PO Box 9746, Portland ME 04104 (2) Johns Hopkins, P.O. Box 8689, Elkridge, MD 21075, (3) Brighton
Marine, PO Box 9195, Watertown MA 02471-9900, (4) St Vincent's NYC, 5 Penn Plaza, 9th Floor, New York NY 10001
Toll-Free Number: (1) 1-888-241-4566, (2) 1-800-801-9322, (3) 1-800-818-8589, (4) 1-800-241-4848
Fax Number: (1) 1-207-828-7822, (2) 1-410-424-4770 , (3) 1-617-923-5898, (4) 1-212-356-4949

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SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED:
TRICARE Prime: Active duty service members have to enroll in TRICARE Prime. (Enrollment is not automatic.)
TRICARE Prime Remote: If eligible, you may be enrolled in TRICARE Prime Remote or TRICARE Prime Remote for
Active Duty Family Members.
TRICARE Overseas Program Prime: Family members 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
2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
(XXX-XX-XXXX) or DoD BENEFITS NUMBER (DBN)

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

(XXXXXXXXX-XX)

3. SPONSOR IS: (X one)

Active Duty

Retired

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

Deceased (Go to Section II.)

Unremarried Former Spouse

5. SPONSOR'S E -MAIL ADDRESS

6. SPONSOR'S
DATE OF BIRTH

c. CELL:

(YYYYMMDD)

b. HOME:

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

New

DRAFT

8. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)

Same as residence

New

9. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT

c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS

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

10. SPONSOR'S REQUESTED ACTION (X one)
None (go to Section II)

Enroll

Transfer Enrollment

PCM Change

Disenroll (Non-AD only)

Effective Date Requested (YYYYMMDD):
11. SPONSOR'S PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability
and your uniformed service guidelines. Review PCM options online or call your Regional Contractor, preferred MTF, or USFHP
member services (non-active duty only) for availability of PCMs.)
a. 1st CHOICE MTF
FULL NAME or MTF/CLINIC
MTF
PRP
(ADSM)
Civilian
b. 2nd CHOICE
MTF

FULL NAME or MTF/CLINIC

Civilian
c. PCM SPECIALTY

No Preference

d. PREFERRED PCM GENDER

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Family/General Practice
No Preference

Male

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Internal Medicine

Flight Medicine

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

c. REQUESTED ACTION :

Enroll

Transfer Enrollment

b. DATE OF BIRTH (YYYYMMDD)

PCM Change

Disenroll

Effective Date Requested (YYYYMMDD):

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

Same as Sponsor

New

e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
a. WORK:
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

No Preference
h. PCM SPECIALTY
i. PREFERRED PCM GENDER

FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC

Family/General Practice
No Preference

Internal Medicine

Male

Enroll

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 Requested (YYYYMMDD):

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

Same as Sponsor

DRAFT

New

e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.

a. WORK:

Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

No Preference
h. PCM SPECIALTY
i. PREFERRED PCM GENDER

FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC

Family/General Practice
No Preference

Internal Medicine

Male

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

c. REQUESTED ACTION :

Enroll

Transfer Enrollment

Pediatrics

Flight Medicine

Female

b. DATE OF BIRTH (YYYYMMDD)

PCM Change

Disenroll

Effective Date Requested (YYYYMMDD):

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

Same as Sponsor

New

e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
a. WORK:
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor or USFHP customer services for availability of PCMs.)

(1) 1st CHOICE

MTF

Civilian

Same as Sponsor

(2) 2nd CHOICE

MTF

Civilian

Same as Sponsor

No Preference
h. PCM SPECIALTY
i. PREFERRED PCM GENDER

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FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC

Family/General Practice
No Preference

Male

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Internal Medicine

Pediatrics

Flight Medicine

Female
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SPONSOR'S SSN/DBN:
SECTION III - REASON FOR DISENROLLMENT OR PCM CHANGE
(Complete if disenrolling or making a PCM change)

Name of Family Member:
Name of Family Member:
Name of Family Member:
Name of Family Member:

Relocation

Dissatisfied

PCS

Other:

Relocation

Dissatisfied

PCS

Other:

Relocation

Dissatisfied

PCS

Other:

Relocation

Dissatisfied

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:

Policy Number:

Policy Effective Date:

Vision Insurance:

Person(s) Covered:

Policy Holder Name:
Policy Number:
Prescription Insurance:

DRAFT
Carrier Name:

Policy Effective Date:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

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

(X if waiving drive time) If my selected or assigned Primary Care Manager (PCM) is greater than a 30 minute drive-time from my
residence, or if I reside outside the Prime Service Area, I hereby waive the drive time standards of thirty minutes for primary care and
one hour for specialty care

I understand if I selected a PCM by name, team, or location (MTF or civilian), TRICARE will enroll me with that PCM subject to PCM
availability and uniformed services policy. I understand that it is my responsibility to comply with all TRICARE Prime, TRICARE Prime
Remote, 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: Your regional contractor will process your enrollment, disenrollment or change request to be effective on the date requested or the
date of event (e.g., initial eligibility, marriage, birth) as appropriate. If your regional contractor receives your enrollment request within 90-days of loss of other
TRICARE or healthcare coverage, your TRICARE Prime coverage can start on the day after the loss of your other coverage provided all enrollment fees are
paid up. You should confirm the enrollment or change before obtaining care by calling your Regional Contractor or by viewing your enrollment on
milConnect (www.tricare.mil/milconnect).
DISENROLLMENT NOTE: If you voluntarily disenroll or do not pay your enrollment fee, you will only have space available care at a military hospital or
clinic. You may re-enroll during the next open enrollment period or within 90-days of a qualifying life event (see www.tricare.mil/LifeEvents for details). If you
don't have an appropriate waiver on file and your address is confirmed ineligible for TRICARE Prime, you will be disenrolled from Prime and automatically
enrolled in TRICARE Select.
PAYMENT OPTIONS: See Section VI on next page.

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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 payment options.
Note 1, Monthly Payment: Monthly payments must be recurring payments, via allotment whenever feasible. You will not receive a monthly bill. If you
select the monthly payment plan, you must make an initial three month payment by check (cashier's or personal check), credit/debit card, or
money order at the time of application. Make checks payable to your regional contractor or your USFHP Designated Provider, as listed on page 1
of this form.
Note 2, Quarterly and Annual Payments: You will be billed on a quarterly or annual basis for credit card payments.
(Your Contractor may offer recurring quarterly and/or annual payments.)
Note 3, Personal Check: Payment by check (money order, cashier's or personal) is limited to the initial three month payment only.
Checks received for ongoing payment will not be accepted.
Note 4, Electronic Funds Transfer: EFT is for monthly or quarterly payments only. The initial payment cannot be made via EFT.
PAYMENT FEE, PLAN AND
METHOD OPTIONS (Some
options are location specific)

MONTHLY

Allotment From Retired Pay

INITIAL 3-MONTH PAYMENT:

Electronic Funds Transfer

Check

QUARTERLY

Credit/Debit Card

ANNUAL

Credit/Debit Card

Money Order

Credit/Debit Card
Credit/Debit Card (Section C below)

A - ALLOTMENT (where feasible, as mandated by law (NDAA for FY2020, Section 702))
I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay.
NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The Uniformed Service member must sign
below. Your Regional Contractor will charge the correct fee amount each month based on your enrollment, individual or family.
(The current rates are at www.tricare.mil/costs)

DRAFT
B - ELECTRONIC FUNDS TRANSFER

ELECTRONIC FUNDS TRANSFER FOR AUTOMATIC PAYMENTS
Name and Address of Financial Institution

Checking (attach voided check)

Name on Account

Telephone Number of Financial Institution

Account Number

ABA Routing Number

Savings

NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family.
(The current rates are at www.tricare.mil/costs)

C - CREDIT/DEBIT CARD
INITIAL 3-MONTH PAYMENT

MONTHLY RECURRING PAYMENTS

Name of Cardholder
CREDIT/DEBIT CARD Number:

Exp. Date (MM/YYYY):

Card Verification Code (CVC) (3-digit number on reverse side of card
NOTE: Your Regional Contractor will charge the correct fee amount based on your enrollment, individual or family. (The current rates are at
www.tricare.mil/costs)

SIGNATURE
My signature authorizes the Regional Contractor to START, CHANGE, or STOP my automated payments as indicated above. Fee amounts, as
determined by TRICARE and subject to change each fiscal year, will be withdrawn between the first and the fifth business day based on the payment
option selected. This authorization will remain in force unless cancelled by me, my Regional Contractor or my financial institution. I understand a
$20.00 administrative fee may be assessed for any payments returned due to insufficient or unavailable funds.
SIGNATURE OF SPONSOR, SPOUSE OR OTHER LEGAL GUARDIAN OF BENEFICIARY

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DATE (YYYYMMDD)

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