Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm) Page 4
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5SPONSOR'S SSN/DBN:
SECTION III - REASON FOR DISENROLLMENT OR PCM CHANGE
Name of Family Member:
Relocation
Dissatisfied
PCS
Other:
Name of Family Member:
Relocation
Dissatisfied
PCS
Other:
Name of Family Member:
Relocation
Dissatisfied
PCS
Other:
Name of Family Member:
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:
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)
If my selected or assigned Primary Care Manager (PCM) is greater than a 30 minute drive-time from my
(X if waiving drive time)
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 if I selected a PCM by name, team, or location (MTF or civilian), the TRICARE Program will enroll me with that PCM
if capacity exists. 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
2. RELATIONSHIP TO SPONSOR
3. DATE SIGNED
(YYYYMMDD)
LEGAL GUARDIAN OF BENEFICIARY
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, MAY 2013
Page 4 of 5 Pages
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