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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 2876-2
for the current year.
DD Form 2876-2 TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form (West)
What Is DD Form 2876-2?
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 2876-2 , 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 the purpose of DD Form 2876-2?A: The form is used for TRICARE Prime enrollment, disenrollment, and PCM changes in the western region.
Q: Who can use DD Form 2876-2?A: This form is for TRICARE beneficiaries in the western region who want to enroll, disenroll, or change their PCM.
Q: Can I use DD Form 2876-2 if I am not in the western region?A: No, this form is specifically for TRICARE beneficiaries in the western region. Other regions have their own forms.
Q: What is a Primary Care Manager (PCM)?A: A PCM is a provider who manages your basic health care needs and coordinates your medical care within the TRICARE system.
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 2876-2 down below in PDF format or browse hundreds of other DoD Forms compiled in our online library.
DD Form 2876-2 Instructions
TRICARE Prime enrollment is available only to those registered in the Defense Enrollment Eligibility Reporting System (DEERS). TRICARE Prime enrollment is available year-round. Get in touch with your regional contractor directly through the TRICARE web page or by filling and submitting the DD 2876-2 Form.
Filling out 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 insurance 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 dutyservice 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.
Download DD Form 2876-2 TRICARE Prime Enrollment, Disenrollment and Primary Care Manager (PCM) Change Form (West)
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