Get the free DD Form 2877, Tricare Prime Disenrollment Application, April 2007 - tricare

TRI CARE PRIME DISENROLLMENT APPLICATION Form Approved OMB No. 0720-0008 Feb 28, 2010 AGENCY DISCLOSURE NOTICE The public reporting burden for this collection of information is estimated to average

How to fill out dd form 2877 tricare

How to fill out DD Form 2877 Tricare:

1. Start by obtaining a blank copy of DD Form 2877 Tricare. This form is used to request authorization for medical and dental care for non-Active Duty Family Members.
2. Begin filling out the form by entering the date in the appropriate field. This should be the date when the form is being completed.
3. Provide your personal information in the designated sections. This includes your full name, Social Security Number, and contact information.
4. Indicate whether you are an Active Duty Service Member or a non-Active Duty Family Member seeking care.
5. Fill in the beneficiary's information, such as their full name, date of birth, Social Security Number, and relationship to the sponsor.
6. Specify the type of care you are requesting authorization for, whether it is medical or dental.
7. Enter the specific details of the care required, including the diagnosis or condition, the name of the provider, the treatment required, and the estimated cost.
8. If applicable, provide any additional information or remarks in the designated section.
9. Next, sign and date the form to certify the accuracy and completeness of the information provided.
10. Once you have completed filling out the form, ensure that all necessary signatures, such as the sponsor's and provider's signatures, are obtained before submitting it for review and authorization by the appropriate authorities.

Who needs DD Form 2877 Tricare:

1. Non-Active Duty Family Members of military personnel who require medical or dental care.
2. This form is required for individuals seeking authorization for medical or dental treatments that fall outside the regular Tricare coverage or require specific approvals.
3. It is important for eligible dependents or beneficiaries to fill out and submit DD Form 2877 Tricare to request approval and ensure the necessary coverage for their healthcare needs.

For pdfFiller’s FAQs

What is dd form 2877 tricare?

DD Form 2877 Tricare is a form used by military service members and their dependents to document any potential liability for third-party medical expenses.

Who is required to file dd form 2877 tricare?

Active duty service members, dependents, retirees, and survivors who have received medical treatment which may be covered by a third party are required to file DD Form 2877.

How to fill out dd form 2877 tricare?

To fill out DD Form 2877 Tricare, you need to provide personal information, details of the medical treatment received, information about the liable third party, and any available insurance information.

What is the purpose of dd form 2877 tricare?

The purpose of DD Form 2877 Tricare is to identify potential sources of recovery for medical treatment costs, ensuring that the appropriate party covers the expenses rather than Tricare.

What information must be reported on dd form 2877 tricare?

DD Form 2877 requires information such as patient and sponsor details, treatment facility information, third-party insurance information, and description of the injury or illness.

When is the deadline to file dd form 2877 tricare in 2023?

The deadline to file DD Form 2877 Tricare in 2023 may vary depending on specific circumstances. It is recommended to contact the appropriate Tricare office or consult the latest guidelines for accurate information.

What is the penalty for the late filing of dd form 2877 tricare?

The penalty for late filing of DD Form 2877 Tricare may result in delayed processing of claims and potentially additional expenses that may need to be covered by the service member or their dependents.

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