Get the free DD Form 2876, TRICARE Prime Enrollment Application and PCM Change Form, March 2004 -...

(Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing this form.) AGENCY DISCLOSURE NOTICE TRI CARE PRIME ENROLLMENT APPLICATION AND PCM CHANGE FORM Approved

How to fill out dd form 2876 tricare

How to Fill out DD Form 2876 Tricare:

1. Start by gathering all the necessary information. You will need your personal details, such as your full name, date of birth, social security number, and contact information.
2. Begin filling out the form by providing your sponsor's information. This includes their full name, social security number, and relationship to you (e.g., spouse, parent, etc.).
3. Next, indicate the type of coverage you are seeking by checking the appropriate box. This could be Prime or Select. Make sure to read the instructions carefully to understand the differences between these options.
4. If you are already enrolled in a different health insurance program, you will need to provide information about it in Section III of the form. This includes the name of the program, policy number, and effective dates.
5. In Section IV, you will need to provide your banking information if you wish to set up electronic fund transfer (EFT) for premium payment. This includes your banking institution's name, routing number, and account number.
6. If you have any other health insurance, you will need to indicate it in Section V. This could be coverage provided through your employer or a separate policy you have purchased.
7. Make sure to review the information you have provided and ensure its accuracy. Mistakes or missing information can delay the processing of your application.
8. Sign and date the form once you have completed all the necessary sections. If you are the sponsor, you will also need to provide your rank, branch of service, and unit.

Who Needs DD Form 2876 Tricare:

1. Active duty service members
2. Reserve and National Guard members
3. Retired service members
4. Military family members
5. Certain former spouses
6. Others eligible for Tricare benefits

Please note that the eligibility criteria for Tricare may vary, so it is essential to refer to the instructions or seek guidance from a Tricare representative if you are unsure.

For pdfFiller’s FAQs

What is dd form 2876 tricare?

DD Form 2876 is the TRICARE Dental Program Enrollment Application and is used to enroll in the TRICARE Dental Program or make changes to an existing enrollment.

Who is required to file dd form 2876 tricare?

Active duty service members, National Guard and Reserve members, and their family members are required to file DD Form 2876 to enroll in or make changes to their TRICARE Dental Program enrollment.

How to fill out dd form 2876 tricare?

To fill out DD Form 2876, you need to provide personal information, such as your name, social security number, address, and contact information. You also need to indicate your eligibility category and select the desired dental plan. Detailed instructions are provided on the form itself.

What is the purpose of dd form 2876 tricare?

The purpose of DD Form 2876 is to enroll in or make changes to the TRICARE Dental Program. It allows eligible individuals to receive dental benefits through the program.

What information must be reported on dd form 2876 tricare?

DD Form 2876 requires the reporting of personal information such as name, social security number, contact details, and eligibility category. Additionally, individuals need to select the desired dental plan and provide any required supporting documentation.

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