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This version of the form is not currently in use and is provided for reference only. Download this version of
DD Form 2876-1
for the current year.
DD Form 2876-1 TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form (East)
What Is DD Form 2876-1?
This is a form that was released by the U.S. Department of Defense (DoD) on July 1, 2016. The form, often mistakenly referred to as the DA Form 2876-1 , is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DoD.
FAQ
Q: What is DD Form 2876-1?A: DD Form 2876-1 is the TRICARE Prime Enrollment, Disenrollment and Primary Care Manager Change Form for the East region.
Q: What is the purpose of DD Form 2876-1?A: The purpose of DD Form 2876-1 is to enroll in or disenroll from TRICARE Prime and to request a change in Primary Care Manager (PCM) for the East region.
Q: Can I use DD Form 2876-1 to enroll in TRICARE Prime outside of the East region?A: No, DD Form 2876-1 is specific to the East region. Other regions have their own enrollment forms.
Q: What information is required on DD Form 2876-1?A: You will need to provide personal information, including your name, address, Social Security number, and beneficiary category. You will also need to select a PCM.
Q: Can I use DD Form 2876-1 to change my PCM?A: Yes, DD Form 2876-1 can be used to request a change in your PCM.
Q: Is there a deadline for submitting DD Form 2876-1?A: TRICARE Prime enrollment and PCM changes must be submitted within 90 days of the eligibility start date or within 90 days of a qualifying life event.
Q: What should I do if I have questions about DD Form 2876-1?A: If you have questions about DD Form 2876-1, you can contact your regional TRICARE contractor or the TRICARE helpline for assistance.
Form Details:
- A 5-page document available for download in PDF;
- The latest version available from the Executive Services Directorate;
- Editable, printable, and free to use;
- Fill out the form in our online filing application.
Download an up-to-date fillable DD Form 2876-1 down below in PDF format or browse hundreds of other DoD Forms compiled in our online library.
DD Form 2876-1 Instructions
TRICARE Prime enrollment is available year-round and only to those service members already registered in the Defense Enrollment Eligibility Reporting System (DEERS). Get in touch with your regional contractor directly through the TRICARE web page to confirm participation or submit a completed copy of the DD 2876-2 Form to the address provided below.
The DD 2876-1 filing process is mostly self-explanatory. Applicants must look through the various payment options provided and choose the TRICARE coverage that suits them best. All individuals filing the form must then provide their personal identifying information, information about their family members, their addresses, and information about their sponsor.
All applicants wishing to enroll in TRICARE are obligated to disclose any information regarding other health insurance they are participating in 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 Eastern Region of the United States is at Humana Military, Attn: PNC Bank, PO Box 105838, Atlanta GA 30348-5838.
Download DD Form 2876-1 TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form (East)
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