Dd Form 1172 PDF Details

The DD Form 1172 serves as a vital bridge connecting service members, their dependents, and various uniformed services benefits. Stepping into the world of military formalities, this application form plays a crucial role in the enrollment process for the Defense Enrollment Eligibility Reporting System (DEERS) and the issuance of the Uniformed Services Identification Card. With sections meticulously designed to gather personal and status information - ranging from name, Social Security Number (SSN), and contact details to medical, marital status, and eligibility dates - the form caters to a comprehensive spectrum of needs and ensures rightful access to privileges ranging from medical and dental care to commissary and exchange facilities. Embodying the Privacy Act and Agency Disclosure Notice, it underscores the significance of informed consent and the protective measures surrounding personal data. The form's layout, while structured to streamline the eligibility verification process, also underlines the responsibilities of sponsors and applicants in maintaining the integrity of the benefits system. Emphasizing voluntary disclosure, it nevertheless hints at potential repercussions for non-compliance, shaping a pathway for beneficiaries to navigate the intricate landscape of uniformed services benefits while upholding a commitment to accuracy and accountability.

QuestionAnswer
Form NameDd Form 1172
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmilitary id renewal form 1172, dd application services, how to dd identification card, dd form 1172

Form Preview Example

Please read Privacy Act Statement and Agency Disclosure Notice prior to completing this form.

 

APPLICATION FOR UNIFORMED SERVICES IDENTIFICATION CARD

OMB No. 0704-0020

 

 

 

DEERS ENROLLMENT

OMB Approval Expires

 

Sep 30, 2008

 

 

 

 

 

1. NAME (Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

2. SEX

3. SSN (or SN)

 

 

 

4. STATUS

 

 

 

5. BR OF SERVICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

PAY GRADE

 

7.

RANK

 

 

 

8. GEN. CAT

9.

TYPE OF CARD ISSUED

 

 

10. ID NO.

 

 

 

11. LAST UPDATE

 

 

 

12. V/I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

CURRENT RESIDENCE ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

14. SUPPLEMENTAL ADDRESS INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

CITY

 

 

 

 

 

 

 

 

16. STATE

17. ZIP CODE

 

 

 

 

 

18. COUNTRY

19. UIC

 

 

 

20. HOME TELEPHONE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

DATE OF BIRTH

 

 

22. BLOOD TYPE

 

23. COLOR EYES

24. COLOR HAIR

 

25. HEIGHT

 

26. WEIGHT

 

 

27. MEDICARE

 

28. MARITAL

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

ELIG ST/MC EFF DATE

30. CARD EX/ELIG

END DATE

31. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)

 

 

 

32. END ELIG REASON

 

(YYYYMMMDD)

 

 

 

(YYYYMMMDD)

 

 

 

Medical

Medical

Commissary Exchange

 

Exchange

Morale, Welfare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civilian

Service

 

 

 

Unlimited

 

Limited

& Recreation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

NAME (Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

34. SEX

35. RELATIONSHIP

 

36. SSN

 

 

 

 

37. ID NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38.

LAST UPDATE

 

 

39. V/I

40. CURRENT RESIDENCE ADDRESS

 

 

 

 

 

 

 

41. SUPPLEMENTAL ADDRESS INFORMATION

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42.

CITY

 

 

 

 

 

 

 

 

43. STATE

44. ZIP CODE

 

 

 

 

 

45. COUNTRY

46. HOME TELEPHONE NO.

 

47. DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

48.

MBI

49. STU

 

50. INCAP

51. MEDICARE

 

52. COLOR EYES

53. COLOR HAIR

 

54. HEIGHT

 

 

 

55. WEIGHT

 

 

 

56. MARITAL STATUS DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

57.

ELIG ST/MC EFF DATE

58. CARD EX/ELIG END DATE

59. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)

 

 

 

60. END ELIG REASON

 

(YYYYMMMDD)

 

 

 

(YYYYMMMDD)

 

 

 

Medical

Medical

Commissary Exchange

 

Exchange

Morale, Welfare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civilian

Service

 

 

 

Unlimited

 

Limited

& Recreation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

61.

NAME (Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

62. SEX

63. RELATIONSHIP

 

64. SSN

 

 

 

 

65. ID NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

66.

LAST UPDATE

 

 

67. V/I

68. CURRENT RESIDENCE ADDRESS

 

 

 

 

 

 

 

69. SUPPLEMENTAL ADDRESS INFORMATION

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

70.

CITY

 

 

 

 

 

 

 

 

71. STATE

72. ZIP CODE

 

 

 

 

 

73. COUNTRY

74. HOME TELEPHONE NO.

 

75. DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

76.

MBI

77. STU

 

78. INCAP

79. MEDICARE

 

80. COLOR EYES

81. COLOR HAIR

 

82. HEIGHT

 

 

 

83. WEIGHT

 

 

 

84. MARITAL STATUS DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

85.

ELIG ST/MC EFF DATE

86. CARD EX/ELIG END DATE

87. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)

 

 

 

88. END ELIG REASON

 

(YYYYMMMDD)

 

 

 

(YYYYMMMDD)

 

 

 

Medical

Medical

Commissary Exchange

 

Exchange

Morale, Welfare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Civilian

Service

 

 

 

Unlimited

 

Limited

& Recreation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

89.

REMARKS (Cite legal documentation, as applicable.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND SEAL

I have read and understand the "Conditions Applicable to Sponsor or Applicant" printed in Section VIII. I certify the

information provided in connection with the eligibility requirements of this form is true and accurate to the best of my knowledge.

(If not signed in the presence of the verifying official, the signature must be notarized.)

90. SIGNATURE

91. DATE SIGNED

 

(YYYYMMMDD)

92.

TYPED NAME (Last, First, Middle)

 

 

93. PAY GRADE

94.

UNIT/COMMAND NAME

95.

TITLE

96. UIC

97. DUTY PHONE NO.

98.

UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)

99.

SIGNATURE

 

100.

DATE VERIFIED

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

101.

TYPED NAME (Last, First, Middle)

 

 

102. PAY GRADE

103.

UNIT/COMMAND NAME

104.

TITLE

105. UIC

106. DUTY PHONE NO.

107.

UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)

108.

SIGNATURE

 

109.

DATE ISSUED

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

RECEIPT OF NEW CARD IS ACKNOWLEDGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

110. SIGNATURE

111. DATE ISSUED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DD FORM 1172, SEP 2005

PREVIOUS EDITION MAY BE USED.

Adobe Professional 6.0

 

This form valid for issue of ID card 90 days from date of verification.

 

The public reporting burden for this collection of information is estimated to average 10 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, Executive Services Directorate (0704-0020). 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 COMPLETED FORM TO THE ABOVE ORGANIZATION.

RETURN COMPLETED FORM TO THE UNIFORMED SERVICE ID CARD ISSUING FACILITY.

SECTION VII - PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. sections 1061 - 1065, 1072 - 1074, 1074a - 1074c, 1076, 1076a, 1077, 1095(k)(2), E.O. 9397.

PRINCIPAL PURPOSE(S): To apply for the Uniformed Services Identification Card and/or DEERS Enrollment.

ROUTINE USE(S): To appropriate business entities, individual providers of care, and others, on matters relating to claims adjudication, program abuse, utilization review, professional quality assurance, medical peer review, program integrity, third party liability, coordination of benefits, and civil and criminal litigation.

To the Department of Health and Human Services, the Department of Veterans Affairs, the Social Security Administration, and to other Federal, state, and local government agencies to identify individuals having benefit eligibility in another plan or program.

Applicant information is subject to computer matching within the Department of Defense or with other Federal or non-Federal agencies. Matching programs are conducted to assure that an individual eligible under a Federal program is not improperly receiving duplicate benefits from another program. A beneficiary or former beneficiary who has applied for privileges of a Federal Benefit Program and has received concurrent assistance under another plan will be subject to adjustment or recovery of any improper payments made or delinquent debts owed.

DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Uniformed Services Identification Card and/or non-enrollment in the Defense Enrollment Eligibility Reporting System. Failure to provide a beneficiary's Social Security Number renders that beneficiary ineligible for health care services in Military Treatment Facilities. However, emergency health care services will be provided to the extent furnished members of the general public.

SECTION VIII - CONDITIONS APPLICABLE TO SPONSOR OR APPLICANT

I understand that the actions of the recipient(s) of the "Uniformed Services Identification Card" issued as a result of this application are my responsibility insofar as proper use of the card for benefits and privileges authorized; i.e., medical and dental care, exchange, commissary, and morale, welfare, and recreation programs. I will cause the recipient to surrender the card immediately upon call to do so or when appropriate under applicable regulations, and will notify an agency designated to grant authorization for privileges and facilities in event of any change in status affecting a recipient's eligibility therefor.

I am aware that medical care furnished in uniformed services facilities is subject to availability of space, facilities, and the capabilities of the medical staff to provide such care. Determinations made by the medical officer or contract surgeon, or his/her designee, as to

availability of space, facilities, and the capabilities of the medical staff shall be conclusive.

Reimbursement shall be required for any unauthor- ized medical and dental care furnished at government expense. Copies of regulations concerning eligibility requirements are available in the Service Personnel Offices.

By signing this document, the sponsor or applicant certifies that he/she is aware that eligibility for benefits under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) terminates for all beneficiaries, except spouses and children of active duty members, and certain disabled beneficiaries under 65, when the beneficiary becomes eligible for Medicare Part A, Hospital Insurance, through the Social Security Administration.

PENALTY FOR PRESENTING FALSE CLAIMS OR MAKING FALSE STATEMENTS

IN CONNECTION WITH CLAIMS: FINE OF UP TO $10,000 OR

IMPRISONMENT FOR UP TO FIVE YEARS OR BOTH.

(ACT June 25, 1948, 18 U.S. Code 287, 1001)

DD FORM 1172 (BACK), SEP 2005

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Filling in part 1 in dd form 1172

2. Right after filling out the previous section, head on to the subsequent step and complete the essential particulars in all these blanks - CITY, STATE ZIP CODE, COUNTRY HOME TELEPHONE NO, Include Area Code, DATE OF BIRTH YYYYMMMDD, MBI, STU, INCAP MEDICARE, COLOR EYES, COLOR HAIR, HEIGHT, WEIGHT, MARITAL STATUS DATE, YYYYMMMDD, and ELIG STMC EFF DATE.

How one can complete dd form 1172 step 2

3. This next stage is simple - fill out all the blanks in UNITCOMMAND ADDRESS Street City, SIGNATURE, DATE ISSUED, YYYYMMMDD, RECEIPT OF NEW CARD IS, DATE ISSUED, YYYYMMMDD, DD FORM SEP, This form valid for issue of ID, PREVIOUS EDITION MAY BE USED, and Adobe Professional to conclude this part.

dd form 1172 conclusion process explained (part 3)

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