DD Form 2876-2 "TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form"

What Is the DD Form 2876-2?

DD Form 2876-2 or the TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form is a form is used to gather the information required enrolling or disenrolling individuals in TRICARE Prime, TRICARE Prime Remote, or Uniformed Services Family Health Plan - specifically within the Western Region of the United States.

The DD 2876-2 is a part of a series of TRICARE-related forms issued by the Department of Defense (DoD) in July 2016.

The DD Form 2876-2 along with the DD 2876-1, DD 2876-3 and the universal DD 2876 are all referred to as the TRICARE Prime Form DD 2876 for short. An up-to-date DD Form 2876-2 fillable copy is available for electronic filing or download below or can be found on the Executive Services Directorate website.

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DD Form 2876-2 Instructions

TRICARE Prime enrollment is available only to those registered in DEERS (Defense Enrollment Eligibility Reporting System). TRICARE Prime enrollment is available year-round. Get in touch with your regional contractor directly through the TRICARE web page or by filing and submitting the DD 2876-2 Form.

Filling out the DD 2876-2 is self-explanatory. Applicants must choose the applicable TRICARE coverage option out of the various payment options provided. All individuals filing must then provide their personal identifying data and information about their relatives as well as their addresses and sponsor information. Applicants enrolling in TRICARE must disclose any information regarding any other health insurances they have at the time of filing.

Prime enrollment applications received on or before the 20th of each month are effective the first calendar day of the next one. All applicants except for active duty service members or those enrolling in TRICARE Overseas Prime or must confirm enrollment and PCM assignment before obtaining medical care.

The TRICARE Regional Contractor Address for the Western Region of the United States is at the Health Net Federal Services, PO Box 8458, Virginia Beach, VA 23450-8458

Toll-free number: 1-844-866-WEST (1-844-866-9378)

Fax number: 1-844-388-8282

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Download DD Form 2876-2 "TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form"

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OMB No. 0720-0008
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND
OMB approval expires
PRIMARY CARE MANAGER (PCM) CHANGE FORM
May 31, 2019
The public reporting burden for this collection of information, 0720-0008, 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-dod-information-collections@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.
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://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.
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
(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://www.dmdc.osd.mil/appj/bwe/.
(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.tricare-west.com
REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS:
Region:
WEST REGION
Address:
Health Net Federal Services, PO Box 8458, Virginia Beach, VA 23450-8458
Toll-Free Number:
1-844-866-WEST (1-844-866-9378)
1-844-388-8282
Fax Number:
UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP):
Address:
(1) USFHP at CHRISTUS Health, PO Box 169001, Irving TX 75016 (2) Pacific Medical Centers, PO Box 84985, Seattle WA
98124
(1) 1-800-678-7347 (2) 1-888-958-7347 option 1
Toll-Free Number:
(1) 1-210-766-8854 (2) 1-206-326-2458
Fax Number:
Page 1 of 5 Pages
DD FORM 2876-2, JUL 2016
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
OMB No. 0720-0008
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND
OMB approval expires
PRIMARY CARE MANAGER (PCM) CHANGE FORM
May 31, 2019
The public reporting burden for this collection of information, 0720-0008, 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-dod-information-collections@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.
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://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.
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
(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://www.dmdc.osd.mil/appj/bwe/.
(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.tricare-west.com
REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS:
Region:
WEST REGION
Address:
Health Net Federal Services, PO Box 8458, Virginia Beach, VA 23450-8458
Toll-Free Number:
1-844-866-WEST (1-844-866-9378)
1-844-388-8282
Fax Number:
UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP):
Address:
(1) USFHP at CHRISTUS Health, PO Box 169001, Irving TX 75016 (2) Pacific Medical Centers, PO Box 84985, Seattle WA
98124
(1) 1-800-678-7347 (2) 1-888-958-7347 option 1
Toll-Free Number:
(1) 1-210-766-8854 (2) 1-206-326-2458
Fax Number:
Page 1 of 5 Pages
DD FORM 2876-2, JUL 2016
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
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)
1. SPONSOR'S NAME
(Last, First, Middle Initial) (Must match DEERS)
or DoD BENEFITS NUMBER (DBN)
(XXX-XX-XXXX)
(XXXXXXXXX-XX)
3. SPONSOR IS:
Active Duty
Retired
Deceased
Unremarried Former Spouse
(X one)
(Go to Section II.)
5. SPONSOR'S E-MAIL ADDRESS
6. SPONSOR'S
4. SPONSOR'S TELEPHONE NUMBER
(Include Area Code)
DATE OF BIRTH
a. WORK:
c. CELL:
(YYYYMMDD)
b. HOME:
7. SPONSOR'S RESIDENCE ADDRESS
New
(Street, Apartment No., City, State, ZIP Code, Country)
8. SPONSOR'S MAILING ADDRESS
Same as residence
New
(Provide APO or FPO if stationed overseas)
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
Enroll
Transfer Enrollment
PCM Change
Disenroll (Non-AD only)
(go to Section II)
Effective Date Requested:
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
FULL NAME or MTF/CLINIC
PRP
MTF
(ADSM)
Civilian
b. 2nd CHOICE
FULL NAME or MTF/CLINIC
MTF
Civilian
Family/General Practice
Flight Medicine
c. PCM SPECIALTY
No Preference
Internal Medicine
d. PREFERRED PCM GENDER
No Preference
Male
Female
DD FORM 2876-2, JUL 2016
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)
12.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
Effective Date
c. REQUESTED ACTION
:
Enroll
Transfer Enrollment
PCM Change
Disenroll
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Same as Sponsor
New
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(1) WORK:
(2) HOME:
(3) 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.)
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
b. DATE OF BIRTH
13.a. FAMILY MEMBER NAME
(YYYYMMDD)
(Last, First, Middle Initial) (Must match DEERS)
Effective Date
Enroll
Transfer Enrollment
PCM Change
Disenroll
c. REQUESTED ACTION:
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Same as Sponsor
New
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(2) HOME:
(3) CELL:
(1) WORK:
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.)
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
14.a. FAMILY MEMBER NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
Effective Date
Enroll
Transfer Enrollment
PCM Change
Disenroll
c. REQUESTED ACTION:
Requested:
d. RESIDENCE AND MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
New
Same as Sponsor
f. E-MAIL ADDRESS
e. TELEPHONE NUMBER
(Include Area Code)
(1) WORK:
(2) HOME:
(3) 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.)
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 2876-2, JUL 2016
Page 3 of 5 Pages
SECTION III REASON FOR DISENROLLMENT OR PCM CHANGE
SPONSOR'S SSN/DBN:
SECTION III - - REASON FOR DISENROLLMENT OR PCM CHANGE
(Complete if disenrolling or making a 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 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
2. RELATIONSHIP TO SPONSOR
3. DATE SIGNED
(YYYYMMDD)
LEGAL GUARDIAN OF BENEFICIARY
ENROLLMENT NOTE: Prime enrollment start dates are based primarily on the 20th of the month rule (applications received on/before the
20th of the month are effective the first calendar day of the next month). You should confirm enrollment and PCM assignment before
obtaining routine medical care. (Note: This does not apply to TRICARE Overseas Prime or to active duty service members.)
DISENROLLMENT NOTE: In some cases, you may not be able to re-enroll in TRICARE Prime for a 12-month period from the date of the
disenrollment. This one year period does not apply to any family member whose sponsor is in grade E-1 to E-4.
PAYMENT OPTIONS: See Section VI on next page.
DD FORM 2876-2, JUL 2016
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 payment options.
Note 1, Monthly Payment: Monthly payments must be recurring payments. 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:
Health Net Federal Services, LLC
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.
Allotment From Retired Pay
Electronic Funds Transfer
MONTHLY
VISA or MasterCard
PAYMENT FEE, PLAN AND
METHOD OPTIONS (Some
INITIAL 3-MONTH PAYMENT:
Check
Money Order
Credit/Debit Card (Section C below)
options are location specific)
VISA or MasterCard
QUARTERLY
ANNUAL
VISA or MasterCard
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)
B - ELECTRONIC FUNDS TRANSFER
ELECTRONIC FUNDS TRANSFER FOR AUTOMATIC PAYMENTS
Checking (attach voided check)
S
avings
Name and Address of Financial Institution
Name on Account
Telephone Number of Financial Institution
Account Number
ABA Routing Number
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
VISA/MASTERCARD MONTHLY RECURRING PAYMENTS:
CREDIT/DEBIT CARD:
Number
:
Exp. Date (MM/YYYY)
Security Code (3-digit number on reverse side of card)
Name of Cardholder
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
DATE
DD FORM 2876-2, JUL 2016
Page 5 of 5 Pages
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