Enrollment – TRICARE Prime / TRICARE Prime Remote

TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form

Use this form to enroll in or disenroll from TRICARE Prime, or to change your primary care manager. New enrollment applications must be received in our offices by the 20th of the month to be effective on the first day of the following month. Portability (transfers) to this region are effective the day the application is received in our offices.

 

  • Created: Dec 20, 2010
  • Modified: Jan 10, 2014
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Enrollment Fee Allotment Authorization letter

TRICARE Prime beneficiaries should use this form to start, change or stop automatic deduction of enrollment fees from their military retirement pay.

 

  • Created: Mar 25, 2014
  • Modified: Mar 25, 2014
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TRICARE Prime Remote Determination of Eligibility Enrollment Request Form

Beneficiaries who have to drive for more than an hour to reach a military treatment facility (MTF) should complete this form to request eligibility for TRICARE Prime Remote (TPR).

If you live or work within 50 miles of an MTF, you will generally not be eligible for TPR.

  • Created: Jun 14, 2011
  • Modified: Jun 14, 2011
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TRICARE Prime Electronic Funds Transfer or Recurring Credit Card Request Form

Use this form to request TRICARE Prime automatic monthly payments by electronic funds transfer (EFT) or recurring credit card (RCC).

  • Created: Mar 25, 2014
  • Modified: Mar 25, 2014
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TRICARE Prime Reconsideration

Use this form to request TRICARE Regional Office – North reconsideration of TRICARE Prime disenrollment for failure to pay enrollment premiums.

  • Created: Apr 2, 2013
  • Modified: Apr 14, 2014
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