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TRICARE YOUNG ADULT APPLICATION (Washington Headquarters Services)

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The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program that allows former dependents to purchase
TRICARE health care plan coverage if qualified. Coverage is extended from age 21 (age 23 if previously enrolled in a full-time course of study at an
institution of higher learning) until reaching age 26 for unmarried dependents that are not eligible for medical coverage from employer-sponsored medical
coverage as a result of their employment.
General eligibility requirements are shown below.
TRICARE YOUNG ADULT APPLICATION
OMB No. 0720-0049
OMB approval expires
6HSWHPEHU
DD FORM 2947-2, SEP 2016
Adobe Professional X
The public reporting burden for this collection of information, 0720-0049, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be
aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
RETURN COMPLETED FORM TO THE DESIRED SERVICING CONTRACTOR SHOWN BELOW.
PRIVACY ACT STATEMENT
This statement informs you of the purpose for collecting personal information required by the TRICARE Young Adult Program and how it will be used.
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care, 32 CFR Part 199, Civilian Health and Medical Program of the Uniformed Serivces
(CHAMPUS); DoD Instruction 1341.2, Defense Enrollment Eligibility Reporting System (DEERS) Procedures; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To collect the information necessary to process your request for coverage, to terminate coverage, or to change your provider.
ROUTINE USE(S): Any protected health information governed by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD by DoD
6025.18-R, may disclosed as permitted under those provisions, which includes for treatment, payment, and healthcare operations. In addition, your records
may be disclosed to the Department of Health and Human Services for use in reports and Medicare determinations. Your records may be disclosed to
Federal agencies, and state, local and territorial governments, in order to collect debts and overpayments, to determine whether beneficiaries are eligible for,
or enrolled in, other government or private health insurance plans, and to stop fraud, waste and abuse. Your records may be disclosed outside of DoD to
support research concerning the health and wellbeing of TRICARE beneficiaries. Your records may also be used and disclosed in accordance with 5
U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD "Blanket Routine Uses" published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
DISCLOSURE: Voluntary. However, failure to provide all requested information may result in denial of your request to enroll
in or change your TRICARE
Young Adult health plan coverage.
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 4 Pages
TRICARE YOUNG ADULT PROGRAM
Sponsor
Status
TRICARE
Prime (1)
TRICARE
Select
Uniformed
Services Family
Health Plan (1)
TRICARE
Overseas Prime
(1)
TRICARE
Overseas
Select
Active Duty Yes Yes Yes Yes Yes
Retired Yes Yes Yes No Yes
Selected Reserve (2) No Yes No No Yes
Retired Reserve (2) No Yes No No Yes
(1) To purchase this coverage, it must be offered in your geographic area and you must meet all other eligibility criteria.
(2) If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be
enrolled in TRICARE Reserve Select or TRICARE Retired Reserve as applicable for you to be eligible to purchase TYA coverage.
For specific information on eligibility, coverage, costs, claims submission, go to: www.tricare.mil/tya
.
ONLINE:
You may electronically complete, submit and print a copy of your enrollment, disenrollment, transfer to another TYA plan, or request a change in an assigned
Primary Care Manager (PCM) by logging into the Beneficiary Web Enrollment (BWE) website at https://www.tricare.mil/bwe/. The BWE website is not
available to beneficiaries in overseas areas.
MAILING THE FORM:
For manual enrollment, disenrollment, or PCM changes in a TRICARE Young Adult plan, complete and submit the form to the address below.
1. Forms may be mailed to the contractor identified below or, with the exception of USFHP applications, taken to a TRICARE Service Center (TSC). Call
your Contractor to determine when your new or transferred enrollment will begin.
2. For enrollment assistance, please call at
3. For additional information on TRICARE, visit the TRICARE website at www.tricare.mil, the Contractor's website at
(TMA BE&SDs/Contractors will add servicing contractor information. Include name, mailing address and web address of contractor, and enrollment fees.)
Uniformed Services Family Health Plan (USFHP) (Include locations, addresses and telephone numbers.)
or your local TRICARE Service Center (TSC).
TRICARE
Prime Remote
(1)
Yes
No
No
No
TRICARE
Overseas Prime
Remote (1)
Yes
No
No
No
Health Net Federal Services
1-844-866-West (9378)
www.tricare-west.com
Health Net Federal Services
PO Box 8458
Virginia Beach, VA 23450-8458
PHONE : 844-866-West (9378) FAX: 844-388-8282
Uniformed Services Family Health Plan (USFHP) – West Region
Website: www.tricare.mil/usfhp
USFHP at CHRISTUS Health
Pacific Medical Centers
PO Box 169001,
Irving, TX 75016
PO Box 84985
Seattle, WA 98124
Phone: 1-800-678-7347
Phone: 1-888-958-7347 option 1
FAX: 1-210-766-8854
FAX: 1-206-326-2458
SECTION II - ENROLLING TRICARE YOUNG ADULT FAMILY MEMBER INFORMATION OR PCM CHANGE
SECTION I - SPONSOR INFORMATION
TRICARE YOUNG ADULT OPTION DESIRED:
TRICARE Select: Includes dependents of sponsors enrolled in the TRICARE Reserve Select and TRICARE Retired Reserve health plans.
TRICARE Prime: Where available. Enrollment is not automatic. If eligible, active duty family members may be enrolled in TRICARE Prime Remote
for Active Duty Family Members (TPRADFM).
TRICARE Overseas Program Prime: For active duty family members only. Must meet specific overseas enrollment criteria. If eligible, may be
enrolled in TRICARE Overseas Prime Remote.
Uniformed Services Family Health Plan (USFHP): Available in six locations. Submit the completed Enrollment Application to the USFHP
address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the TRICARE website at
www.tricare.mil/usfhp
.
1. SPONSOR'S NAME (Last, First, Middle Initial) (Must match DEERS)
2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
(XXX-XX-XXXX) or DoD BENEFITS NUMBER (DBN)
(XXXXXXXXX-XX)
6. SPONSOR'S RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code, Country)
4. SPONSOR'S TELEPHONE NUMBER (Include Area Code)
a. WORK:
3. SPONSOR IS: (X one)
Active Duty Retired
c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESSa. UNIT
8. SPONSOR'S MILITARY ASSIGNMENT
Deceased (Go to Section II.)
b. UNIT IDENTIFICATION CODE (UIC) (If known)
b. RESIDENTIAL:
5. SPONSOR'S E-MAIL ADDRESS
(X box to receive TRICARE e-mails)
New
7. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)
Same as residence New
9. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
10. DATE OF BIRTH (YYYYMMDD)
16. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime or USFHP plan, or requesting a PCM change. Please
list your first and second choices below. Honoring your preference depends upon availability and local Military Treatment Facility (MTF) policy. Contact
your TRICARE Service Center, preferred MTF, or US Family Health Plan Member Services for availability of PCMs. If no PCM preference is indicated,
one will be assigned.)
11. REQUESTED ACTION:
12. RESIDENCE ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Enroll Transfer Enrollment PCM Change Disenroll Effective Date:
Same as Sponsor
New
14. TELEPHONE NUMBER (Include Area Code)
a. WORK:
b. RESIDENTIAL:
15. E-MAIL ADDRESS
(X box to receive TRICARE e-mails)
No Preference
a. 1st CHOICE
Family/General Practice
Internal Medicine
FULL NAME or MTF/CLINIC
c. PCM SPECIALTY
Pediatrics
MTF
Civilian
Flight Medicine
Same as Sponsor
b. 2nd CHOICE
FULL NAME or MTF/CLINIC
MTF
Civilian Same as Sponsor
d. PREFERRED PCM GENDER
No Preference Male Female
17. REASON FOR DISENROLLMENT OR PCM CHANGE
Relocation Dissatisfied with PCM PCS
Other:Have employer-sponsored health care coverage Marriage
DD FORM 2947-2, SEP 2016
Page 2 of 4 Pages
Selected Reserve
Retired Reserve
13. MAILING ADDRESS
(Provide address, with ZIP Code and
Country, if different from Sponsor)
Same as Residence
New
SPONSOR'S SSN/DBN:
SECTION III - OTHER HEALTH INSURANCE
18. PLEASE IDENTIFY IF YOU ARE CURRENTLY COVERED BY OTHER HEALTH INSURANCE.
TRICARE Supplement (no other information is needed)
Medical Insurance: Person(s) Covered:
Policy Holder Name: Carrier Name:
Policy Number: Policy Effective Date:
Dental Insurance: Person(s) Covered:
Policy Holder Name: Carrier Name:
Policy Number: Policy Effective Date:
Vision Insurance: Person(s) Covered:
Policy Holder Name: Carrier Name:
Policy Number: Policy Effective Date:
Prescription Insurance: Person(s) Covered:
Policy Holder Name: Carrier Name:
Policy Number:
I am eligible to enroll in an employer-sponsored health plan offered through my employer.
I am married.
20. DATE SIGNED (YYYYMMDD)19. SIGNATURE OF YOUNG ADULT DEPENDENT APPLICANT
COMPLETION IS MANDATORY - X YES OR NO FOR EACH STATEMENT
Yes No
Yes No
SECTION IV - ACCESS WAIVER, ATTESTATIONS, AND SIGNATURE (REQUIRED)
I understand that if I selected a Primary Care Manager (PCM) by name, team, or location (MTF or civilian), the TRICARE program will
enroll me with that PCM if capacity exists. If my selected or assigned PCM is greater than a 30 minute drive-time from my residence, or if
I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time
from my residence, and (2) this application constitutes my agreement to waive both the primary care access standard and specialty care
access standard as applicable.
I understand recurring monthly premium payments may be adjusted as necessary based on a desired change in TYA coverage or due to
changes in monthly premium amounts required by law.
I understand that it is my responsibility to comply with all TRICARE Young Adult policies and procedures. By signing this form, I certify
the information provided is true, accurate, and complete. Federal funds are involved in this program and any false claims, statements,
comments, or concealment of a material fact may be subject to fine and/or imprisonment under applicable Federal law.
ENROLLMENT NOTE: Initial enrollment effective date for TRICARE Select coverage is the 1st of the month following the month the
application is received, or the 1st of the month requested up to 90 days in the future. Effective dates for TRICARE Prime coverage are
based primarily on the 20th of the month rule (applications received by the 20th of the month are effective the first day of the next month).
If a TYA application is received by the contractor or postmarked within 30 days after termination of previous TRICARE coverage, you can
request an effective coverage date immediately following termination of your previous TRICARE coverage. You should confirm enrollment
(and PCM assignment for Prime plans) before obtaining routine medical care by calling your contractor.
DISENROLLMENT NOTE: You may incur a 12 month lock-out from TRICARE Young Adult coverage for failure to pay premiums or for
voluntary termination not associated with gaining employer-sponsored health plan coverage. You may not be allowed to re-enroll in
TRICARE Young Adult for 12 months from the date of the disenrollment.
PAYMENT OPTIONS: See Section V on the next page.
DD FORM 2947-2, SEP 2016
Page 3 of 4 Pages
SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS
21. PREMIUM PAYMENT METHOD (X and complete as applicable.) (See www.tricare.mil/costs for current rates.)
Failure to complete both parts a. and b. of this section when requesting new and/or recurring TYA coverage will result in your
application being returned without action.
a. INITIAL PREMIUMS (Two months of initial premiums are required.)
Check/Money Order/Cashier's Check
(Enclose applicable premium payable to contractor on first page.)
PAYMENT AMOUNT: $
Visa/MasterCard Credit or Debit Card:
CARD NUMBER: EXPIRATION DATE (MM/YYYY):
NAME OF
CARDHOLDER:
CARDHOLDER
SIGNATURE:
CARDHOLDER
BILLING ADDRESS:
b. RECURRING AUTOMATED MONTHLY PREMIUMS (Recurring monthly premiums must be paid via a Recurring Credit Charge on a
Visa/MasterCard credit or debit card or an Electronic Funds Transfer from a checking or savings account; either option is initiated and
maintained by your servicing contractor. Failure to ensure premiums can be paid monthly via automated means will result in termination of TYA
coverage.)
Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.
Other Visa/MasterCard Credit or Debit Card:
CARD NUMBER: EXPIRATION DATE (MM/YYYY):
NAME OF
CARDHOLDER:
CARDHOLDER
SIGNATURE:
CARDHOLDER
BILLING ADDRESS:
Electronic Funds Transfer (EFT). From:
Checking (Optional - attach voided check) or
Savings
NAME AND ADDRESS OF
FINANCIAL INSTITUTION
NAME ON ACCOUNT
ACCOUNT NUMBER
ACCOUNT HOLDER
SIGNATURE
TELEPHONE NUMBER OF
FINANCIAL INSTITUTION
BANK OR ABA ROUTING NUMBER
DD FORM 2947-2, SEP 2016
Page 4 of 4 Pages
SPONSOR'S SSN/DBN:
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Completed 16 September 2020

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