Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm) Page 3
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5SPONSOR'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
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. REQUESTED ACTION:
Enroll
Transfer Enrollment
PCM Change
Disenroll Effective Date:
d. RESIDENCE/MAILING ADDRESS
Same as Sponsor
(Provide address, with ZIP Code and
New
Country, if different from Sponsor)
e. TELEPHONE NUMBER
f. E-MAIL ADDRESS
(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.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
12.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. REQUESTED ACTION:
Enroll
Transfer Enrollment
PCM Change
Disenroll Effective Date:
d. RESIDENCE/MAILING ADDRESS
Same as Sponsor
(Provide address, with ZIP Code and
New
Country, if different from Sponsor)
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.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
13.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. REQUESTED ACTION:
Enroll
Transfer Enrollment
PCM Change
Disenroll Effective Date:
d. RESIDENCE/MAILING ADDRESS
Same as Sponsor
(Provide address, with ZIP Code and
New
Country, if different from Sponsor)
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.)
FULL NAME or MTF/CLINIC
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
FULL NAME or MTF/CLINIC
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
Family/General Practice
Flight Medicine
No Preference
Internal Medicine
Pediatrics
i. PREFERRED PCM GENDER
No Preference
Male
Female
DD FORM 2876, MAY 2013
Page 3 of 5 Pages
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