Dd Form 2837 PDF Details

If you are a member of the military, then you may have had to fill out a DD Form 2837. This form is used to request permission to be absent from duty for more than three days. It can also be used to request leave for certain types of travel. If you are new to the military or have never filled out this form before, it can be confusing and difficult to know what information is required. This blog post will provide a brief overview of the DD Form 2837 so that you can understand what information is needed and how to complete it correctly. Stay safe and always follow your chain of command!

QuestionAnswer
Form NameDd Form 2837
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesDD214, osd, CHCBP, OMB

Form Preview Example

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)

SUMMARY

WHAT IS THE CHCBP?

The Continued Health Care Benefit Program (CHCBP) is a program of temporary health benefit coverage for certain eligible individuals who lose military health benefits. The CHCBP is premium based, with the medical benefits under this program mirroring the benefits offered in the TRICARE Standard Program and functioning under most of the rules and procedures of TRICARE Standard.

ARE THERE SPECIFIC ENROLLMENT

REQUIREMENTS?

Yes. Beneficiaries must elect coverage in the CHCBP within 60 days following: (1) loss of entitlement to the Military Health System; or

(2)being notified of the CHCBP. Beneficiaries may not select the effective date of their CHCBP policy; the period of coverage must begin on the day after loss of military entitlement.

WHO IS ELIGIBLE?

(1)The sponsor; (2) certain unremarried former spouses; (3) a child who loses military benefits due to his or her age; and (4) a child placed in the legal custody of the sponsor.

WHAT ARE THE ENROLLMENT CATEGORIES?

CHCBP provides two types of coverage plans: individual and family. Individual coverage is available to the sponsor, an unremarried former spouse, and a child losing military benefits due to age. Family coverage is only available to the separating service member and his or her family members. Once the election is made, the sponsor's enrollment category can be changed from individual to family coverage under the following conditions:

(1)birth of a child; (2) marriage of the sponsor; (3) legal adoption of a child by the sponsor; or (4) placement by a court of a child as a legal ward in the home of the sponsor. If one of the above events has occurred, the former member can change his or her enrollment from individual to family coverage, effective as of the date of the qualifying event. The sponsor must send a written request to Humana Military Healthcare Services, Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201, no later than 60 days from the qualifying event and must include sufficient documentation to support the change in enrollment categories.

HOW DOES ONE ENROLL IN THE CHCBP?

In order to enroll in the CHCBP, an eligible individual must submit a completed enrollment application form, proof of eligibility, and payment in full for the first 90 days of coverage (check or money order made payable to the United States Treasury). The enrollment form may be requested from Humana Military Healthcare Services, Inc., by writing or calling them. The enrollment form can also be found on the Web at www.tricare.osd.mil or www.humana-military.com.

PROOF OF ELIGIBILITY:

Proof of eligibility must be submitted with the completed enrollment application and payment. The documentation that is required is shown in Sections 6(1) through 6(5) of the enrollment application, depending on the category of the individual applying. Additional information and documentation may be requested to confirm the applicant's eligibility.

HOW LONG IS COVERAGE OFFERED?

CHCBP coverage ranges from a period of 18 to

36 months, depending on the category of the beneficiary. Former active duty members and their family members are entitled to purchase up to 18 months of coverage. All other eligible beneficiaries are entitled to 36 months of coverage. Certain former spouses may be eligible for coverage beyond 36 months. All former spouses should review the criteria for extended coverage before enrolling in CHCBP to determine their eligibility for continued coverage beyond 36 months. CHCBP coverage is offered in increments of 90 days, renewable up to the total number of months referenced above.

WHAT DOES CHCBP COVERAGE COST?

The cost of CHCBP coverage depends on the category of enrollment, either individual or family. The premium for individual coverage is $933.00 per quarter and the premium for family coverage is $1,996.00 per quarter.

HOW IS COVERAGE RENEWED?

At least thirty days prior to the expiration of the current coverage period, a renewal notice will be sent to the enrollee. The enrollee must return the renewal notice and payment in full, by check, money order or major credit card, no later than 30 days after the end of the current coverage period. Failure to renew within the required time will result in the permanent loss of entitlement to purchase any additional CHCBP coverage.

DD FORM 2837 INSTRUCTIONS, OCT 2001

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)

SUMMARY (Continued)

ARE PREMIUMS REFUNDABLE?

Refunds of premiums paid for CHCBP coverage are not refundable other than in extraordinary circumstances, e.g., if the enrollee is no longer eligible for CHCBP coverage.

WHAT BENEFITS ARE OFFERED?

Health care coverage under the CHCBP mirrors the coverage of the TRICARE Standard benefit, which covers a majority of medical conditions. However, for some types of treatment, coverage can be limited. Prior to enrolling in the CHCBP, interested beneficiaries are encouraged to contact a TRICARE Service Center to ask specific questions regarding TRICARE Standard coverage.

WHAT ADDITIONAL COSTS ARE THERE?

When medical care is received, the beneficiary will be responsible for payment of certain deductible and cost-sharing amounts in connection with otherwise covered services and supplies. For detailed information concerning the amounts of cost-shares and deductibles, beneficiaries are encouraged to contact a TRICARE Service Center nearest their home.

HOW TO FILE A CLAIM:

Enrollees may request the provider to file medical claims on their behalf. If the provider does not file the claim, the enrollee will have to do so. It is helpful to attach a copy of the CHCBP enrollment card to the claim. Information regarding where to submit a claim can be found at the TRICARE Web Site www.tricare.osd.mil or by contacting either Humana Military Healthcare Services, Inc., or a TRICARE Service Center nearest the enrollee's residence.

If there are any problems with the processing of a CHCBP claim, the enrollee should contact the claims processor. If that is not successful, the enrollee may then write to the TRICARE Management Activity at the following address:

Beneficiary and Provider Services

TRICARE Management Activity

16401 East Centretech Parkway

Aurora, CO 80011-9066

HOW CAN PROVIDERS VERIFY CHCBP ELIGIBILITY?

Providers may call 1-800-444-5445 to verify the eligibility of the beneficiary or to obtain basic CHCBP information.

WHAT STEPS SHOULD ACTIVE DUTY MEMBERS TAKE WHEN SEPARATING FROM THE MILITARY?

Current active duty members anticipating separation from the military should ensure they participate in pre-separation counseling, which will provide information regarding various benefits available to members after leaving the military. Former members must also ensure that their correct status is recorded in DEERS upon separation.

HOW TO OBTAIN INFORMATION ABOUT CHCBP:

Humana Military Healthcare Services, Inc., provides administrative and educational support for the CHCBP. As part of this effort, they operate a toll-free line 24 hours a day. Beneficiary Service Representatives are available Monday through Friday 8:00 a.m. to 7:00 p.m. Eastern Time (except holidays).

ADDITIONAL INFORMATION:

Write or call:

Humana Military Healthcare Services, Inc.

Attn: CHCBP

P.O. Box 740072

Louisville, KY 40201

1-800-444-5445

or visit their Web Site at: www.humana-military.com

DD FORM 2837 INSTRUCTIONS (BACK), OCT 2001

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)

APPLICATION

Form Approved

OMB No. 0704-0364

Expires Jun 30, 2002

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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0364), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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 APPLICATION TO THE ABOVE ADDRESS. RETURN COMPLETED APPLICATION WITH PREMIUM PAYMENT TO: Humana Military Healthcare Services, Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 1086 and E.O. 9397.

PRINCIPAL PURPOSE(S): This form is used by certain former military health care beneficiaries to apply for coverage under the Continued Health Care Benefit Program (CHCBP). Please see 32 C.F.R. 199.20(d) for a list of the eligible beneficiaries.

ROUTINE USE(S): Disclosure may be made to Federal, state, local, foreign government agencies, private business entities and individual providers of care on matters relating to entitlement, fraud, program abuse, program integrity, or civil and criminal litigation related to the operation of the Continued Health Care Benefit Program.

DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in the applicant not being enrolled in the Continued Health Care Benefit Program.

1.

APPLICANT NAME (Last, First, Middle Initial)

2.

TELEPHONE NO. (Include Area Code)

 

 

 

 

 

a. HOME

 

b. WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code)

4.

MAILING ADDRESS (If different from Residence Address)

 

 

 

 

 

 

 

 

 

 

5.

SERVICE MEMBER SPONSOR THROUGH WHOM YOU QUALIFY (If different from Applicant)

 

 

 

 

 

 

 

 

 

 

 

 

a.

NAME (Last, First, Middle Initial)

 

 

b. SPONSOR'S SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

6.

PERSON(S) TO BE ENROLLED IN CHCBP (Including Applicant)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. NAME

 

 

 

b. SSN

c. DATE OF BIRTH

d. SEX

 

 

(Last, First, Middle Initial)

 

 

OF INDIVIDUAL

(YYYYMMDD)

(M/F)

 

 

 

 

 

 

 

 

 

 

(1)SPONSOR (Submit copy of DD214 - Member 4 Copy)

(2)DEPENDENTS

(Submit copy of DD214 - Member 4 Copy)

(Sponsor must enroll for dependents to be enrolled. List all family members. Use a separate sheet

of paper if more space is needed.)

(3)UNREMARRIED FORMER SPOUSE (Submit copy of final divorce decree.)

(4)CHILD LOSING MILITARY BENEFITS DUE TO AGE*

(Submit copy of Military ID Card)

(5)CHILD LOSING MILITARY BENEFITS FOR ANY OTHER REASON* (Submit copy of proof of event that resulted in loss of benefits.)

*Children age 21 (23 if a full-time student) losing military coverage must apply separately for their own individual policy. If more than three children, use separate sheet of paper.

7.TOTAL THREE-MONTH PREMIUM ENCLOSED: (Individual three-month premium is $933.00. Family three-month premium is $1,996.00.)

$

PAID BY:

CHECK

PREMIUM PAID IS FOR:

 

INDIVIDUAL COVERAGE

 

FAMILY COVERAGE

 

 

 

 

 

MONEY ORDER (Check/money order payable to the United States Treasury)

8. APPLICANT'S SIGNATURE AND DATE

By signing this form, the applicant is certifying that the information provided on this form is true, accurate and complete. Federal funds are involved in this program and any false claims, statements, comments or concealment of a material fact may be subject to fine and imprisonment under applicable Federal law.

a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

DD FORM 2837, OCT 2001

PREVIOUS EDITION IS OBSOLETE.

Return this copy

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)

APPLICATION

Form Approved

OMB No. 0704-0364

Expires Jun 30, 2002

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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0364), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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 APPLICATION TO THE ABOVE ADDRESS. RETURN COMPLETED APPLICATION WITH PREMIUM PAYMENT TO: Humana Military Healthcare Services, Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 1086 and E.O. 9397.

PRINCIPAL PURPOSE(S): This form is used by certain former military health care beneficiaries to apply for coverage under the Continued Health Care Benefit Program (CHCBP). Please see 32 C.F.R. 199.20(d) for a list of the eligible beneficiaries.

ROUTINE USE(S): Disclosure may be made to Federal, state, local, foreign government agencies, private business entities and individual providers of care on matters relating to entitlement, fraud, program abuse, program integrity, or civil and criminal litigation related to the operation of the Continued Health Care Benefit Program.

DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in the applicant not being enrolled in the Continued Health Care Benefit Program.

1.

APPLICANT NAME (Last, First, Middle Initial)

2.

TELEPHONE NO. (Include Area Code)

 

 

 

 

 

a. HOME

 

b. WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code)

4.

MAILING ADDRESS (If different from Residence Address)

 

 

 

 

 

 

 

 

 

 

5.

SERVICE MEMBER SPONSOR THROUGH WHOM YOU QUALIFY (If different from Applicant)

 

 

 

 

 

 

 

 

 

 

 

 

a.

NAME (Last, First, Middle Initial)

 

 

b. SPONSOR'S SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

6.

PERSON(S) TO BE ENROLLED IN CHCBP (Including Applicant)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. NAME

 

 

 

b. SSN

c. DATE OF BIRTH

d. SEX

 

 

(Last, First, Middle Initial)

 

 

OF INDIVIDUAL

(YYYYMMDD)

(M/F)

 

 

 

 

 

 

 

 

 

 

(1)SPONSOR (Submit copy of DD214 - Member 4 Copy)

(2)DEPENDENTS

(Submit copy of DD214 - Member 4 Copy)

(Sponsor must enroll for dependents to be enrolled. List all family members. Use a separate sheet

of paper if more space is needed.)

(3)UNREMARRIED FORMER SPOUSE (Submit copy of final divorce decree.)

(4)CHILD LOSING MILITARY BENEFITS DUE TO AGE*

(Submit copy of Military ID Card)

(5)CHILD LOSING MILITARY BENEFITS FOR ANY OTHER REASON* (Submit copy of proof of event that resulted in loss of benefits.)

*Children age 21 (23 if a full-time student) losing military coverage must apply separately for their own individual policy. If more than three children, use separate sheet of paper.

7.TOTAL THREE-MONTH PREMIUM ENCLOSED: (Individual three-month premium is $933.00. Family three-month premium is $1,996.00.)

$

PAID BY:

CHECK

PREMIUM PAID IS FOR:

 

INDIVIDUAL COVERAGE

 

FAMILY COVERAGE

 

 

 

 

 

MONEY ORDER (Check/money order payable to the United States Treasury)

8. APPLICANT'S SIGNATURE AND DATE

By signing this form, the applicant is certifying that the information provided on this form is true, accurate and complete. Federal funds are involved in this program and any false claims, statements, comments or concealment of a material fact may be subject to fine and imprisonment under applicable Federal law.

a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

DD FORM 2837, OCT 2001

PREVIOUS EDITION IS OBSOLETE.

Retain this copy

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Stage number 1 of filling in form 2837 fillable

2. Once your current task is complete, take the next step – fill out all of these fields - claim Information regarding where, Write or call, can be found at the TRICARE Web, wwwtricareosdmil or by contacting, Humana Military Healthcare, Military Healthcare Services Inc, Attn CHCBP, Center nearest the enrollees, PO Box, Louisville KY, If there are any problems with the, CHCBP claim the enrollee should, processor If that is not, then write to the TRICARE, and or visit their Web Site at with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing part 2 in form 2837 fillable

3. The following segment is about CONTINUED HEALTH CARE BENEFIT, APPLICATION, Form Approved OMB No Expires Jun, The public reporting burden for, PRIVACY ACT STATEMENT, AUTHORITY USC and EO PRINCIPAL, APPLICANT NAME Last First Middle, TELEPHONE NO Include Area Code, RESIDENCE ADDRESS Street, MAILING ADDRESS If different from, a HOME, b WORK, SERVICE MEMBER SPONSOR THROUGH, a NAME Last First Middle Initial, and b SPONSORS SOCIAL SECURITY NUMBER - complete these blank fields.

Filling out part 3 of form 2837 fillable

People generally get some things incorrect while filling in MAILING ADDRESS If different from in this part. Ensure that you go over whatever you type in here.

4. This next section requires some additional information. Ensure you complete all the necessary fields - SPONSOR Submit copy of DD Member, DEPENDENTS Submit copy of DD, UNREMARRIED FORMER SPOUSE Submit, CHILD LOSING MILITARY BENEFITS, CHILD LOSING MILITARY BENEFITS, Children age if a fulltime, and TOTAL THREEMONTH PREMIUM ENCLOSED - to proceed further in your process!

Completing segment 4 of form 2837 fillable

5. As you draw near to the last parts of your form, you will find a few extra points to do. Mainly, TOTAL THREEMONTH PREMIUM ENCLOSED, INDIVIDUAL COVERAGE, PREMIUM PAID IS FOR, FAMILY COVERAGE, PAID BY, CHECK, MONEY ORDER Checkmoney order, APPLICANTS SIGNATURE AND DATE By, a SIGNATURE, b DATE SIGNED YYYYMMDD, DD FORM OCT, PREVIOUS EDITION IS OBSOLETE, and Return this copy must all be done.

Filling in segment 5 of form 2837 fillable

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