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NOTE Once disenrolled you will incur a 12 month lock-out from TRICARE Prime. You will not be allowed to re-enroll in TRICARE Prime for 12 months from the date of the sponsor is in the grade of E-1 to E-4. 6. Please keep a copy of the completed application for your records. 7. For information on TRICARE contact the local TRICARE Service Center TSC or visit the TRICARE website at www. DATE OF BIRTH YYYYMMDD c. RELATIONSHIP TO SPONSOR Self Spouse Former Spouse Child d. REASON FOR DISENROLLMENT X...

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What is tricare prime disenrollment application?

Tricare Prime disenrollment application is a form used to request to disenroll from Tricare Prime health care program.

Who is required to file tricare prime disenrollment application?

Any individual who wishes to disenroll from Tricare Prime is required to file the disenrollment application.

How to fill out tricare prime disenrollment application?

To fill out the Tricare Prime disenrollment application, you need to provide personal information, reasons for disenrollment, and submit the form to the appropriate office.

What is the purpose of tricare prime disenrollment application?

The purpose of Tricare Prime disenrollment application is to formally request to leave the Tricare Prime health care program.

What information must be reported on tricare prime disenrollment application?

Information such as personal details, reasons for disenrollment, and any supporting documentation must be reported on the Tricare Prime disenrollment application.

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