US Family Health Plan Enrollment Application

TRICARE PRIME ENROLLMENT

OMB No. 0720-0008 OMB approval expires December 31, 2028
The public reporting burden for this collection of information 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, [email protected]. 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.

PRIVACY ACT STATEMENT AUTHORITY
10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17; 32 CFR 199.17; and E.O. 9397 (SSN), as amended. PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to enroll, disenroll, or change their provider in TRICARE Prime, TRICARE Prime Remote, or the Uniformed Services Family Health Plan, as requested by the individual. ROUTINE USE(S): Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, as implemented by DoD 6025.18-R, the DoD Health Information Privacy Regulation. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the DoD "Blanket Routine Uses" under 5 U.S.C. 552a(b)(3) apply to this collection. A complete listing of the routine uses permitted under 5 U.S.C. 552a(b)(3) is published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Collected information may be shared with the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and other Federal, State, local, or foreign government agencies, private business entities, including entities under contract with the Department of Defense and individual providers of care, on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or criminal litigation. DISCLOSURE: Voluntary; however, your failure to provide all the requested information may result in the denial of the request to enroll in, transfer, or terminate your TRICARE Prime health plan coverage.

Note: Enter a ZIP code for one of the people enrolling in the plan. This is an initial service area check to confirm the ZIP code is within our service area. You'll enter each enrollee's full address later in the application.

For active-duty families: if the sponsor is stationed outside the service area, you may use the ZIP code where an enrolling spouse or dependent lives instead.