Fillable Dd Form 2947 - Tricare Young Adult Application (Page 2 of 2) in pdf

UNIFORMED SERVICES SPONSOR THROUGH WHOM APPLICANT QUALIFIES FOR COVERAGE

12. NAME (Last, First, Middle Initial)

13. SOCIAL SECURITY NUMBER (SSN)

14. DATE OF BIRTH

OR DoD BENEFITS NUMBER (If known)

(YYYYMMDD)

15. STATUS (X one)

Active Duty

Retired

Selected Reserve

Retired Reserve

Transitional Assistance Management Program

16. PREMIUM PAYMENT METHOD (Two months of initial premiums are required) (X as applicable)

Check/Money Order/Cashiers Check for initial payments only

2 MONTHS OF PREMIUMS NOW DUE:

(Enclose applicable premium payable to contractor listed below)

Visa/Mastercard initial payments only (NOT monthly payments)

Visa/Mastercard initial and automatic monthly payments

CARD NUMBER:

EXPIRATION DATE (MM/YYYY):

NAME OF

CARDHOLDER

CARDHOLDER:

SIGNATURE:

Electronic Funds Transfer - automatic monthly payments

Checking (attach voided check)

Savings

NAME AND ADDRESS OF

FINANCIAL INSTITUTION:

NAME ON

TELEPHONE NUMBER OF

ACCOUNT:

FINANCIAL INSTITUTION:

ACCOUNT NUMBER:

BANK OR ABA ROUTING NUMBER:

17. APPLICANT'S SIGNATURE AND DATE

By signing this form, I understand that it is my responsibility to comply with all TRICARE Young Adult requirements. I certify the

information provided on this form 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 imprisonment under applicable Federal and State laws.

I certify that I am not eligible to enroll in an employer-sponsored health plan offered through my employer as defined by Section 5000A(f)(2) of

the IRS Code of 1986. If I should become eligible to enroll in an employer-sponsored health plan offered through my employer as defined by

Section 5000A(f)(2) of the IRS Code of 1986, I will submit a request to terminate my TRICARE Young Adult coverage.

I certify that I am not married.

I certify that I understand that a nonsufficient funds fee will be charged whenever a financial institution rejects a premium payment transaction

due to insufficient funds.

Complete as necessary if purchasing Prime coverage. If I am outside the service area, I understand and accept that my travel time to the

network of primary care delivery sites may exceed 30 minutes from my home to the delivery site and my travel time for specialty care may

exceed 1 hour.

Complete as desired. If available, I elect to receive TRICARE Young Adult information, premium statements, and benefit change

correspondence via e-mail or by links to websites.

a. APPLICANT SIGNATURE

b. DATE SIGNED (YYYYMMDD)

TRICARE YOUNG ADULT PROGRAM

Submission of this form does not automatically result in a requested action. You must meet all qualifications for coverage and pay

appropriate premiums. Policy premiums are updated annually.

The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program. Coverage is extended

from age 21 (age 23 if enrolled in a full-time course of study at an institution of higher learning approved by the Secretary of Defense)

up to age 26 for unmarried dependents that are not eligible for medical coverage from an eligible employer-sponsored health plan as a

result of their employment.

Qualified dependents can purchase either the TRICARE Prime or Standard/Extra benefits based upon meeting specific program

requirements and the availability of a desired plan in their geographic location.

For information on eligibility, enrollment, coverage, costs, claims submission, and additional program information, go to:

or contact the servicing contractor listed below:

US Family Health Plan - Christus Health

TRICARE Young Adult Monthly Premium - 2012

P.O. Box 924708

$201 per month

Houston, TX 77292-4708

1-800-678-7347

TRICARE Young Adult Monthly Premium - 2013

$176 per month

DD FORM 2947 (BACK), SEP 2012

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Dd Form 2947 - Tricare Young Adult Application Page 2

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