Dd Form 2853 – Fill Out and Use This PDF

The DD Form 2853 is the official enrollment application for TRICARE Plus, a health care program tailored specifically for TRICARE beneficiaries who seek primary care services at Military Treatment Facilities (MTFs) but are not eligible for TRICARE Prime or opt for a more constrained primary care option. This form collects necessary information to process the enrollment requests and outlines the guidelines for eligibility, submission, and the implications of enrolling in TRICARE Plus. For those interested in taking advantage of the primary care services offered by MTFs through TRICARE Plus, ensure to fill out the form accurately by clicking the button below.

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Dd Form 2853 PDF Details

The process of enrolling in TRICARE Plus, a healthcare program designed for certain beneficiaries of the Uniformed Services' healthcare system, is initiated through the submission of the DD Form 2853. This form, which plays a critical role in facilitating access to primary care services at Military Treatment Facilities (MTFs), requests detailed information from applicants to ensure a smooth enrollment. By collecting data such as sponsor identification, mailing and residence addresses, chosen MTF, and primary care provider preferences, the form serves as a vital step in connecting eligible beneficiaries with military healthcare services. Furthermore, the form's instructions emphasize the importance of accuracy and completeness, highlighting obligations such as updating the Defense Enrollment Eligibility Reporting System (DEERS) information and retaining a copy of the form for personal records. Notably, the DD Form 2853 also outlines the program's scope, including limitations regarding specialty care access and potential out-of-pocket expenses for services outside the MTF, thereby setting clear expectations for applicants. This underscores the form's role not only as a procedural document but also as an informational resource for prospective enrollees, guiding them through the nuances of TRICARE Plus enrollment.

Question	Answer
Form Name	Dd Form 2853
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	dd2853 form, dd form 2853 fillable, tricare plus enrollment application, dd form 2853 feb 2014

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TRICARE PLUS ENROLLMENT APPLICATION	OMB No. 0720-0028
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before	OMB approval expires
completing form.)	Feb 28, 2017

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 7 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, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0720-0028). 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.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. Return completed form to the Military Treatment Facility where you are requesting treatment.

PRIVACY ACT STATEMENT

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.

PRINCIPAL PURPOSE(S): This form collects the information necessary to process your request to enroll in TRICARE Plus.

ROUTINE USE(S): 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. Use and disclosure of your records outside of DoD may occur 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://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html.

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 by DoD 6025.18-R. Permitted uses and disclosures of PHI include,

but are not limited to, treatment, payment, and healthcare operations.

DISCLOSURE: Voluntary; however, failure to provide the requested information may result in the denial of your request to enroll in TRICARE Plus.

INSTRUCTIONS

This form is for eligible beneficiaries who want to enroll in TRICARE Plus. TRICARE Plus is an enrollment option for TRICARE beneficiaries who want an affiliation with a primary care provider at a Military Treatment Facility (MTF) and are either ineligible for TRICARE Prime or prefer a more limited relationship (primary care only). Enrollment in TRICARE Plus does not guarantee access to services at the MTF, however, if you are accepted for enrollment you will be assigned to a primary care provider at the MTF. The MTF will make every effort to provide complete and comprehensive primary care services within access standards. Beneficiaries enrolled into TRICARE Plus agree to rely on their MTF primary care provider for all their non-emergency primary care.

GENERAL INSTRUCTIONS:

1.Print all information in ink. Make sure the information is complete and accurate.

2.Ensure personal information matches information in the Defense Enrollment Eligibility Reporting System (DEERS). To check your DEERS information, call the Defense Manpower Data Center Support Office at 1-800-538-9552 or refer to your name as printed on your ID card. The mailing address and telephone numbers you include on this form will update DEERS.

3.Sign and date the application (Section III).

4.Please keep a copy of the completed application for your records.

5.Submit completed application to the MTF where you are requesting enrollment. Each MTF has local policies for processing your application. For more information regarding enrollment to a specific MTF, contact the MTF directly.

6.For information on TRICARE Plus, contact any MTF or visit the TMA Website at www.tricare.osd.mil.

DD FORM 2853 INSTRUCTIONS, FEB 2014	PREVIOUS EDITION IS OBSOLETE.	Adobe Professional X
		Adobe Professional X

TRICARE PLUS ENROLLMENT APPLICATION

(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)

SECTION I - SPONSOR INFORMATION (Must be completed on all applications)

1. Sponsor Social Security Number	2. Sponsor Name (Last, First, Middle Initial)	3. Date of Birth
(SSN) or DoD Benefits Number (DBN)		(YYYYMMDD)

SECTION II - INDIVIDUAL ENROLLMENTS

4. Sponsor Requesting Enrollment

a. Mailing Address (Street/P.O. Box, Apartment Number, b. Residence Address (If different from mailing address) City, State, ZIP Code)


c. Telephone Number		(1) Home:			(2) Work:
(Include area code):		(1) Home:			(2) Work:
(Include area code):
d. Sponsor's E-mail Address:						X to receive TRICARE e-mails

e. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice			(2) Second Choice
	X if under the care of this provider or MTF			X if under the care of this provider or MTF
	X if under the care of this provider or MTF			X if under the care of this provider or MTF
For	Government Use Only

5. Enrolling Family Members
a. Name (Last, First, Middle Initial)					b. Date of Birth (YYYYMMDD)

c. Mailing Address (Street/P.O. Box, Apartment Number,			d. Residence Address (If different from mailing address)
City, State, ZIP Code)
	X if same as sponsor			X if same as sponsor
	X if same as sponsor			X if same as sponsor
e.	Telephone Number	(1) Home:			(2) Work:
(Include area code):		(1) Home:			(2) Work:
(Include area code):
f. Requested Military Treatment Facility (MTF) and Provider's Name (If known)
(1) First Choice			(2) Second Choice
	X if under the care of this provider or MTF			X if under the care of this provider or MTF
	X if under the care of this provider or MTF			X if under the care of this provider or MTF
For	Government Use Only

SECTION III - SIGNATURE

6.I understand that TRICARE Plus:

(1)is a military treatment facility primary care enrollment program, not a comprehensive health plan; (2) does not guarantee access to specialty care at the military treatment facility where the beneficiary is enrolled; (3) enrollees may have out-of-pocket expenses for civilian health care; (4) enrollment at this military treatment facility is not transferable to another military treatment facility; and (5) by enrolling in TRICARE Plus I will be disenrolled from any other TRICARE enrollment program.

By signing this form, I certify that the information on this form is true, accurate and complete.

a. Signature

b. Date Signed (YYYYMMDD)

Return ORIGINAL completed form to the Military Treatment Facility where you are requesting treatment. Keep a copy for your records.

DD FORM 2853, FEB 2014

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1. The tricare plus enrollment application needs particular details to be typed in. Ensure that the next blank fields are completed:

2. After the last array of fields is complete, you're ready put in the essential particulars in Enrolling Family Members a Name, b Date of Birth YYYYMMDD, c Mailing Address StreetPO Box, d Residence Address If different, X if same as sponsor, e Telephone Number Include area, Home, Second Choice, X if same as sponsor Work, X if under the care of this, X if under the care of this, For Government Use Only, SECTION III SIGNATURE, and I understand that TRICARE Plus in order to move on to the next stage.

3. The following step is focused on I understand that TRICARE Plus, b Date Signed YYYYMMDD, and Return ORIGINAL completed form to - type in each one of these fields.

Return ORIGINAL completed form to, I understand that TRICARE Plus, and b Date Signed YYYYMMDD of dd 2853

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Dd Form 2853 – Fill Out and Use This PDF

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