Dd Form 2814 PDF Details

Designed to streamline the process of enrolling in the TRICARE Pharmacy Redesign Pilot Program, the DD 2814 form serves a crucial function for military health services beneficiaries. Recognized officially as a Pharmacy Redesign Pilot Program Enrollment form, its structure facilitates the collection of essential information, ranging from sponsor and family member enrollment details to other health insurance coverage. Carefully formulated instructions on the form guide individuals through each section, ensuring that the necessary data is provided accurately. The form encompasses personal specifics, such as names, social security numbers, and contact details, alongside more intricate insurance details. Furthermore, it includes payment instructions for the program, offering options for both annual and semi-annual payments, making it imperative to understand for those interested in obtaining or continuing their pharmacy benefits under the TRICARE system. With stipulations set for voluntary disclosure, the form emphasizes the importance of accurate information, as any discrepancies could lead to enrollment denial, highlighting its significance in the broader context of military health care services. The DD 2814 form thus bridges the gap between military families and their access to critical pharmacy care, reinforcing the ongoing commitment to their health and well-being.

QuestionAnswer
Form NameDd Form 2814
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdod-dd-2814, Okeechobee, TRICARE, 2000

Form Preview Example

PHARMACY REDESIGN PILOT PROGRAM ENROLLMENT

Form Approved

OMB No. 0720-0023

(Read Privacy Act Statement and Payment Instructions on back before completing this form.)

Expires Jul 31, 2003

 

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 and Communications Directorate (0720-0023). 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 APPROPRIATE ADDRESS ON BACK.

1. SPONSOR INFORMATION

a. NAME (Last, First, Middle)

 

 

b. SOCIAL SECURITY

c. DATE OF BIRTH

 

 

d. SEX (X one)

 

 

 

 

NUMBER

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. DECEASED (X one)

 

 

 

f. SPONSOR ENROLLING (X one)

 

 

 

 

 

YES

 

NO

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) STREET (Include apartment number)

 

(2) CITY

 

 

(3) STATE

 

(4) ZIP CODE

 

 

 

 

 

 

 

 

 

 

h. TELEPHONE NUMBERS (Include area code)

 

i. OTHER HEALTH INSURANCE (X one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) HOME

 

(2) WORK

 

 

YES (If Yes, complete Item 3.)

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j. IN CASE OF EMERGENCY, CONTACT:

(2) ADDRESS (Street, City, State, ZIP Code)

 

(3) TELEPHONE NUMBER

(1) NAME (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

 

(Include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.FAMILY MEMBER ENROLLMENT (List all family members requesting enrollment. All family members must be registered in DEERS.) (Use additional pages if necessary.)

a.

(1)

NAME (Last, First, Middle)

(2)

 

SOCIAL SECURITY

(3) DATE OF BIRTH

(4)

RELATIONSHIP TO

 

 

 

 

NUMBER

(YYYYMMDD)

 

SPONSOR

 

 

 

 

 

 

 

 

 

 

 

 

(5)

ADDRESS (f different from sponsor) (Street, City,

 

 

(6) TELEPHONE NUMBERS (If different from

(7)

OTHER HEALTH

 

 

State, ZIP Code)

 

 

 

sponsor) (Include area code)

 

INSURANCE (X one)

 

 

 

 

 

 

(a) HOME

(b) WORK

 

 

YES (If Yes, complete

 

 

 

 

 

 

 

 

 

 

NO

Item 3.)

 

 

 

 

 

 

 

 

 

 

(8)

IN CASE OF EMERGENCY, CONTACT:

(b)

ADDRESS (Street, City, State, ZIP Code)

(c) TELEPHONE NUMBER

 

(a) NAME (Last, First, Middle Initial)

 

 

 

 

 

 

(Include area code)

 

 

 

 

 

 

 

 

 

b.

(1)

NAME (Last, First, Middle)

(2)

 

SOCIAL SECURITY

(3) DATE OF BIRTH

(4)

RELATIONSHIP TO

 

 

 

 

NUMBER

(YYYYMMDD)

 

SPONSOR

 

 

 

 

 

 

 

 

 

 

(5)

ADDRESS (f different from sponsor) (Street, City,

 

(6) TELEPHONE NUMBERS (If different from

(7)

OTHER HEALTH

 

 

State, ZIP Code)

 

 

 

sponsor) (Include area code)

 

INSURANCE (X one)

 

 

 

 

 

(a) HOME

(b) WORK

 

 

YES (If Yes, complete

 

 

 

 

 

 

 

 

 

 

NO

Item 3.)

 

 

 

 

 

 

 

 

 

(8)

IN CASE OF EMERGENCY, CONTACT:

(b)

ADDRESS (Street, City, State, ZIP Code)

(c) TELEPHONE NUMBER

 

(a) NAME (Last, First, Middle Initial)

 

 

 

 

 

 

(Include area code)

 

 

 

 

 

 

 

 

 

 

 

 

3.OTHER HEALTH INSURANCE (Complete only if you have other HEALTH insurance.)

a. INSURANCE COMPANY NAME

b. TYPE OF COVERAGE

c. POLICY NUMBER

d. EXPIRATION DATE

 

(X one)

 

 

 

(YYYYMMDD)

 

 

FULL

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLEMENTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. ADDRESS (Street, City, State, ZIP Code)

 

f. TELEPHONE NUMBER

g. DOES YOUR POLICY HAVE PRESCRIPTION DRUG

 

 

(Include area code)

COVERAGE? (X one)

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

4. SPONSOR OR ENROLLEE SIGNATURE

 

 

 

 

5. DATE SIGNED (YYYYMMDD)

 

 

 

 

DD FORM 2814, NOV 2000

PREVIOUS EDITION IS OBSOLETE.

 

PRIVACY ACT STATEMENT

AUTHORITY: 44 USC Sec. 101; 10 USC 1079 and 1088; 38 USC Sec. 13; EO Sec. 387.

PRINCIPAL PURPOSE(S): To evaluate for medical care provided by civilian sources to Military Health Services beneficiaries applying for coverage under the TRICARE Program (32 CFR, Part 198.17).

ROUTINE USE(S): Information from application forms and related documents may be given to the Department of Defense, Health and Human Services, and/or Transportation consistent with their statutory administrative responsibilities under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); to the Department of Justice for representation of the Secretary of Defense in civil actions; and to Congressional Offices in response to inquiries made in the request of the person to whom a record pertains. Appropriate disclosure may be made to other Federal, state, local, and foreign government agencies, private business entities, and individual providers of care, on matters relating to fraud, program abuse, program integrity, and civil and criminal litigation related to the operation of the TRICARE Program.

DISCLOSURE: Voluntary; however, failure to provide information will result in denial of enrollment.

PAYMENT INSTRUCTIONS

Mail all TRICARE Pharmacy Redesign Pilot Program enrollment forms to:

Region 3 (Okeechobee, FL area)

Humana Military Healthcare Services Attn: Pharmacy Pilot Program Enrollment 500 West Main Street

515 Building, 3rd Floor P.O. Box 740072 Louisville, KY 40201-7472

Region 5 (Fleming, KY area)

Anthem Alliance Health Insurance

Attn: Pharmacy Redesign Pilot Program Enrollment

333 W. First Street, Suite 210

Dayton, OH 45402

Complete credit card information below or attach a check or money order payable to Anthem Alliance Health Insurance or Humana Military Healthcare Services and include it with your enrollment form.

Credit Card: Type

 

Visa

 

Master Card

 

Other

Credit Card Number

Expiration Date (MMYY)

Cardholder's Name

Cardholder's Signature

Payment Methods: Indicate the payment method you have chosen, the number of persons enrolling (i.e. Retiree/Sponsor 1 , Retiree Family Member(s) 1 ), and the total payment you are enclosing.

(1) Annual Payment Method:

$200.00 per person per year.

Retiree/Sponsor

Retiree Family Member(s)

Total Payment

$

(2)Semi-annual Payment Method:

$100.00 per person at the time of enrollment, and $100.00 per person 6 months after each beneficiary is enrolled into the program.

Retiree/Sponsor

Retiree Family Member(s)

Total Payment

$

DD FORM 2814 (BACK), NOV 2000

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In an effort to complete this PDF form, ensure you enter the right details in every field:

1. Before anything else, once completing the USC, start with the part containing following blanks:

Filling in segment 1 in dd 2814

2. Once your current task is complete, take the next step – fill out all of these fields - INSURANCE X one, YES If Yes complete NO, Item, c TELEPHONE NUMBER, Include area code, NAME Last First Middle, SOCIAL SECURITY, DATE OF BIRTH, RELATIONSHIP TO, NUMBER, YYYYMMDD, SPONSOR, ADDRESS f different from sponsor, State ZIP Code, and TELEPHONE NUMBERS If different with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Stage # 2 in completing dd 2814

Always be extremely careful when filling out c TELEPHONE NUMBER and State ZIP Code, as this is the part in which most users make errors.

3. Throughout this stage, have a look at Complete credit card information, Credit Card Type, Visa, Master Card, Other, Credit Card Number Expiration Date, Cardholders Signature, Payment Methods Indicate the, Annual Payment Method, per person per year, RetireeSponsor, Retiree Family Members, Total Payment, Semiannual Payment Method, and per person at the time of. Each of these should be completed with greatest precision.

Part # 3 in submitting dd 2814

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