Young Adult Application Form – Fill Out and Use This PDF

The public reporting burden for this collection of information, 0720-0049, 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 the Department of Defense, Washington Headquarters Services, at whs.mc- alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.

RETURN COMPLETED FORM TO THE DESIRED SERVICING CONTRACTOR SHOWN BELOW.

PRIVACY ACT STATEMENT

This statement informs you of the purpose for collecting personal information required by the TRICARE Young Adult Program 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); DoD Instruction 1341.02, Defense Enrollment Eligibility Reporting System (DEERS) Program and Procedures; and E.O. 9397 (SSN), as amended.

PURPOSE: To collect the information necessary to process your request for coverage, to terminate coverage, or to change your provider.

ROUTINE USE(S): Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Collected information may also be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or foreign government agencies, or authorized private business entities. Additionally, information may be shared with the contractor responsible for management of the system. For a full listing of the Routine Uses, please refer to the applicable SORN. 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 discloses of PHI include, but are not limited to, treatment, payment, and healthcare operations.For a full listing of the applicable Routine Uses for the system, refer to the applicable SORN.

APPLICABLE SORN: DMDC 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS) (October 16, 2019, 84 FR 55293) is the system of records notice (SORN) applicable

to DD 2947. The SORN can be found at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/

DISCLOSURE: Voluntary. However, failure to provide all requested information may result in a denial of your request to enroll in or change your TRICARE Young Adult health plan coverage.

TRICARE YOUNG ADULT PROGRAM

The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program that allows former dependents to purchase TRICARE health care plan coverage if qualified. Coverage is extended from age 21 (age 23 if previously enrolled in a full-time course of study at an institution of higher learning) until reaching age 26 for unmarried dependents that are not eligible for medical coverage from employer-sponsored medical coverage as a result of their employment.

General eligibility requirements are shown below.

Sponsor	TRICARE	TRICARE	TRICARE	Uniformed	TRICARE	TRICARE	TRICARE
Status	Prime (1)	Prime Remote	Select	Services Family	Overseas Prime	Overseas Prime	Overseas
		(1)		Health Plan (1)	(1)	Remote (1)	Select
Active Duty	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Retired	Yes	No	Yes	Yes	No	No	Yes
Selected Reserve (2)	No	No	Yes	No	No	No	Yes
Retired Reserve (2)	No	No	Yes	No	No	No	Yes

(1)To purchase this coverage, it must be offered in your geographic area and you must meet all other eligibility criteria.

(2)If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be enrolled in TRICARE Reserve Select or TRICARE Retired Reserve as applicable for you to be eligible to purchase TYA coverage.

For specific information on eligibility, coverage, costs, claims submission, go to www.tricare.mil/tya.

APPLICATION OPTIONS

ONLINE:

You may electronically complete, submit and print a copy of your enrollment, disenrollment, transfer to another TYA plan, or request a change in an assigned Primary Care Manager (PCM) by logging into the Beneficiary Web Enrollment (BWE) website at http://milconnect.dmdc.osd.mil.

MAILING THE FORM:

For manual enrollment, disenrollment, or PCM changes in a TRICARE Young Adult plan, complete and submit the form to the address below.

1. Forms may be mailed to the contractor identified below. Call your Contractor to determine when your new or transferred enrollment will begin.

2. For enrollment assistance, please call	Humana Military		1-800-444-5445

3. For additional information on TRICARE, visit the TRICARE website at www.tricare.mil, the Contractor's website at

HumanaMilitary.com

Humana Military

PO Box 538025

Atlanta, GA 30353-8025

Phone: 1-800-444-5445 FAX: 1-866-836-9535

Uniformed Services Family Health Plan (USFHP) – East Region

Website: www.tricare.mil/usfhp

Uniformed Services Family Health Plan (USFHP) (Include locations, addresses and telephone numbers.)

DD FORM 2947-1, APRIL 2021

PREVIOUS EDITION IS OBSOLETE.

YOUNG ADULT SSN/DBN:

TRICARE YOUNG ADULT OPTION DESIRED:

TRICARE Select: Includes dependents of sponsors enrolled in the TRICARE Reserve Select and TRICARE Retired Reserve health plans.

TRICARE Prime: Where available. Enrollment is not automatic. If eligible, active duty family members may be enrolled in TRICARE Prime Remote for Active Duty Family Members (TPRADFM).

Uniformed Services Family Health Plan (USFHP): Available in six locations. Submit the completed Enrollment Application to the USFHP address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the TRICARE website at www.tricare.mil/usfhp.

SECTION I - SPONSOR INFORMATION

SECTION II - ENROLLING TRICARE YOUNG ADULT FAMILY MEMBER INFORMATION OR PCM CHANGE

11. REQUESTED ACTION:	Enroll	Transfer Enrollment	PCM Change	Disenroll	Effective Date
12. RESIDENCE ADDRESS		Same as Sponsor
(Provide address, with ZIP Code and
Country, if different from Sponsor)		New
13. MAILING ADDRESS		Same as Residence
(Provide address, with ZIP Code and
Country, if different from Sponsor)		New

b. RESIDENTIAL:

16.PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime or USFHP plan, or requesting a PCM change. Please

list your first and second choices below. Honoring your preference depends upon availability and local Military Treatment Facility (MTF) policy. Contact your preferred MTF, or US Family Health Plan Member Services for availability of PCMs. If no PCM preference is indicated, one will be assigned.)

				FULL NAME or MTF/CLINIC
a. 1st CHOICE	MTF	Civilian	Same as Sponsor
				FULL NAME or MTF/CLINIC
b. 2nd CHOICE	MTF	Civilian	Same as Sponsor

d. PREFERRED PCM GENDER	No Preference		Male	Female
17. REASON FOR DISENROLLMENT OR PCM CHANGE		Relocation	Dissatisfied with PCM	PCS

DD FORM 2947-1, APRIL 2021

PREVIOUS EDITION IS OBSOLETE.

YOUNG ADULT SSN/DBN:

SECTION III - OTHER HEALTH INSURANCE

18. PLEASE IDENTIFY IF YOU ARE CURRENTLY COVERED BY OTHER HEALTH INSURANCE.

TRICARE Supplement (no other information is needed)

Medical Insurance:	Person(s) Covered:
Policy Holder Name:	Carrier Name:
Policy Number	Policy Effective Date:
Dental Insurance:	Person(s) Covered:
Policy Holder Name:	Carrier Name:
Policy Number	Policy Effective Date:
Vision Insurance:	Person(s) Covered:
Policy Holder Name:	Carrier Name:
Policy Number	Policy Effective Date:
Prescription Insurance	Person(s) Covered:
Policy Holder Name:	Carrier Name:
Policy Number	Policy Effective Date:

SECTION IV - ACCESS WAIVER, ATTESTATIONS, AND SIGNATURE (REQUIRED)

I understand that if I selected a Primary Care Manager (PCM) by name, team, or location (MTF or civilian), the TRICARE program will enroll me with that PCM if capacity exists. If my selected or assigned PCM is greater than a 30 minute drive-time from my residence, or if I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time from my residence, and (2) this application constitutes my agreement to waive both the primary care access standard and specialty care access standard as applicable.

I understand recurring monthly premium payments may be adjusted as necessary based on a desired change in TYA coverage or due to changes in monthly premium amounts required by law.

I understand that it is my responsibility to comply with all TRICARE Young Adult policies and procedures. By signing this form, I certify the information provided is true, accurate, and complete. Federal funds are involved in this program and any false claims, statements, comments comments, or concealment of a material fact may be subject to fine and/or imprisonment under applicable Federal law.

ENROLLMENT NOTE: Your regional or USFHP contractor will process your enrollment, disenrollment, or change request for coverage to be effective on the date of receipt or up to 90 days in the future as requested by you. If the contractor receives your enrollment request within 90 days of loss of other TRICARE or healthcare coverage, you may request your TYA coverage to start on the day after the loss of your other coverage. You should confirm enrollment (and PCM assignment for Prime plans) or PCM changes before obtaining care by calling your Regional or USFHP contractor, or by viewing your enrollment on https:// milconnect.dmdc.osd.mil

DISENROLLMENT NOTE: You may incur a lock-out from TRICARE Young Adult coverage for failure to pay premiums or for voluntary termination not associated with gaining employer-sponsored health plan coverage.

PAYMENT OPTIONS: See Section V on the next page.

DD FORM 2947-1, APRIL 2021

PREVIOUS EDITION IS OBSOLETE.

YOUNG ADULT SSN/DBN:

SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS

21.PREMIUM PAYMENT METHOD (X and complete as applicable.) (See www.tricare.mil/costs for current rates.)

Failure to complete both parts a. and b. of this section when requesting new and/or recurring TYA coverage will result in your application being returned without action.

a. INITIAL PREMIUMS: To purchase TYA coverage, young adult dependents should submit an application request along with an initial 2- month payment by check (cashier's or personal check), money order, or credit/debit card at the time of enrollment.

Check/Money Order/Cashier's Check				PAYMENT AMOUNT: $
(Enclose applicable premium payable to contractor on first page.)
Visa/MasterCard Credit or Debit Card:
CARD NUMBER:				EXPIRATION DATE (MM/YYYY)
NAME OF			CARDHOLDER
CARDHOLDER:			SIGNATURE:
CARDHOLDER
BILLING ADDRESS:

b. RECURRING AUTOMATED MONTHLY PREMIUMS (Recurring monthly premiums must be paid via a Recurring Credit Charge on a Visa/MasterCard credit or debit card, or an Electronic Funds Transfer from a checking or savings account. All options are initiated through and maintained by your servicing contractor.)

Acknowledgment Required

Failure to pay monthly premiums by automated means will result in termination of TYA coverage.

Payment Options

Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.

Other Visa/MasterCard Credit or Debit Card:
CARD NUMBER:					EXPIRATION DATE (MM/YYYY)
NAME OF				CARDHOLDER
CARDHOLDER:				SIGNATURE:
CARDHOLDER
BILLING ADDRESS:

ACCOUNT NUMBER

BANK OR ABA ROUTING NUMBER

ACCOUNT HOLDER

SIGNATURE

DD FORM 2947-1, APRIL 2021

PREVIOUS EDITION IS OBSOLETE.