Arja Tayar Karne Form – Fill Out and Use This PDF

TYA Reconsideration Request Form

Please type or print all entries.

	TYA (Young Adult) Sponsor and Beneficiary Information				Select Coverage Type:	☐Prime		☐Standard
Sponsor Name: Last		First			M.I.		Sponsor SSN or DBN
Home Address: Street		Apt. No.	City				State	ZIP Code
Mailing Address: Street		Apt. No.	City				State	ZIP Code
If different then above
Sponsor E-Mail Address:
Day Time Phone Number:					Evening Phone Number:
TYA Beneficiary Name: Last		First			M.I.		TYA Beneficiary SSN or DBN
TYA Home Address: Street		Apt. No.	City				State	ZIP Code
TYA Mailing Address: Street		Apt. No.	City				State	ZIP Code
If different then above
TYA Beneficiary E-Mail Address:

Step 1: Please specify the action you are requesting.

☐Please Reinstate coverage. If approved, your coverage will be continuous from your last paid through date when enrollment fees have been paid current as required by your plan. Any claims for health care services received during your disenrollment would then be covered by TRICARE if approved.

Step 2: Please provide a DETAILED explanation why requesting to be reinstated.

Detailedreasonforreconsiderationisrequired. Ifmorespaceisneeded,pleaseattachanadditionalpage.

Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.

TRICARE West Region Customer Service: 1-877-988-9378(WEST) - www.uhcmilitarywest.com

“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select,” and “TRICARE Retired Reserve” are registered trademarks of the

Defense Health Agency. All Rights Reserved.

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Please note: If you have been disenrolled for failure to pay your TRICARE enrollment fees, TRICARE policy states that you will be unable to enroll for 12 months. You may be eligible for reinstatement or to retroactively enroll in certain circumstances. The enrollment department and or DHA will review your request as submitting this form does not guarantee approval.

Step 3: Please provide supporting documentation as applicable.

Proof of payment, fax confirmation, written documentation and/or print outs etc.

Step 4: Sign Request Form TYA Signature is Required and CANNOT be processed if not provided

TYA Signature____________________________________________________________ Date___________________

**Request will not be processed without this signature**

Step 5: Please mail or fax to the address below.

Mail this form to:	or Fax this form to:
UnitedHealthcare Military & Veterans	1-877-890-7297
TRICARE West Region Enrollment Department
P.O. Box 105492	THANK YOU FOR YOUR SERVICE!
Atlanta, GA 30348-5492

** Please note: All three pages must be completed and submitted in order for request to be processed. **

Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.

TRICARE West Region Customer Service: 1-877-988-9378(WEST) - www.uhcmilitarywest.com

“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select,” and “TRICARE Retired Reserve” are registered trademarks of the

Defense Health Agency. All Rights Reserved.

UHCMV0891_09292014

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Privacy Act Statement

This statement serves to inform you of the purpose for collecting personal information required by the UnitedHealthcare Military & Veterans Information System 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 Services (CHAMPUS); and E.O. 9397 (SSN), as amended.

PURPOSE: To collect information from you in order to manage your TRICARE enrollment, provide your benefits, and/or pay for those services.

ROUTINE USES: Your records may be disclosed to investigate waste, fraud, abuse, security, and privacy concerns. Use and disclosure of your records outside of DoD may also occur in accordance with the DoD Blanket Routine Uses published at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed, but absence of the requested information may result in administrative delays or the inability to process your request.

Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as “official use only.” Violations of this may be punishable by fines, imprisonment, or both.

TRICARE West Region Customer Service: 1-877-988-9378(WEST) - www.uhcmilitarywest.com

“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select,” and “TRICARE Retired Reserve” are registered trademarks of the

Defense Health Agency. All Rights Reserved.

UHCMV0891_09292014

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