Get the free DD Form 2876, TRICARE Prime Enrollment, Disenrollment, and PCM Change Form, 20130321...

OMB No. 0720-0008 OMB approval expires Feb 29, 2016 TRI CARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CARE MANAGER (PCM) CHANGE From The public reporting burden for this collection of information

How to fill out dd form 2876 tricare

How to fill out DD Form 2876 Tricare:

1. Start by obtaining a copy of DD Form 2876 Tricare from a trusted source such as the official Tricare website or your healthcare provider.
2. Carefully read the instructions provided with the form to familiarize yourself with its purpose and requirements.
3. Begin by filling out the top section of the form, which includes the patient's personal information such as full name, date of birth, Social Security Number, and address.
4. Proceed to the next section, which requires you to provide details about the sponsoring sponsor, such as their name, Social Security Number, and relationship to the patient.
5. If you are the spouse or child of an active duty service member, fill out the section titled "Sponsor's Duty Status." Mark the appropriate box to indicate the sponsor's current status (active duty, National Guard/Reserves, etc.).
6. Next, indicate whether the patient is enrolled in any other health insurance plans by marking the relevant box in the section titled "Health Insurance Information."
7. If the patient has any secondary insurance coverage, provide the necessary details in the following section, including the name of the insurance provider and policy number.
8. Moving on, indicate the patient's preferred healthcare provider by providing their name, address, and contact information.
9. If the patient has any specific medical conditions or needs that should be considered, briefly describe them in the section titled "Special Needs."
10. Once you have completed all the required sections, review the form to ensure all the information provided is accurate and up to date.
11. Sign and date the form in the designated area at the bottom to certify the accuracy of the information provided.
12. Keep a copy of the filled-out DD Form 2876 Tricare for your records and submit the original to the appropriate Tricare administration office or mailing address.

Who needs DD Form 2876 Tricare?

1. Active duty service members who sponsor their family members for healthcare coverage under Tricare.
2. Dependents of active duty service members who are eligible for Tricare benefits.
3. Retired service members and their qualified dependents who are enrolled in Tricare for Life or Tricare Plus.
4. Surviving family members of deceased service members who receive Tricare benefits.

It is important to note that the specific eligibility requirements for using DD Form 2876 Tricare may vary depending on individual circumstances and the current Tricare policies in place. It is recommended to consult the official Tricare website or contact Tricare customer service for the most accurate and up-to-date information.

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What is dd form 2876 tricare?

DD Form 2876 is a form used by TRICARE to collect information about other health insurance (OHI) coverage that beneficiaries may have.

Who is required to file dd form 2876 tricare?

Beneficiaries who have other health insurance (OHI) coverage are required to file DD Form 2876 with TRICARE.

How to fill out dd form 2876 tricare?

DD Form 2876 can be filled out online or by mail. Beneficiaries must provide information about their other health insurance coverage on the form.

What is the purpose of dd form 2876 tricare?

The purpose of DD Form 2876 is to help TRICARE coordinate benefits with other health insurance coverage that beneficiaries may have.

What information must be reported on dd form 2876 tricare?

Information that must be reported on DD Form 2876 includes details about the other health insurance coverage, policy number, and coverage dates.