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Enrollment – TRICARE Prime/TRICARE Prime Remote

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

Beneficiaries can enroll in or disenroll from TRICARE Prime, or to change your primary care manager online through Beneficiary Web Enrollment (BWE) or you can print, complete and mail this form to Health Net Federal Services, LLC for processing.

Note: ADSMs must have their orders or unit identification code (UIC) available when enrolling to ensure assignments to local military hospitals or clinics are accurate.

  • Created: Dec 20, 2010
  • Modified: Apr 3, 2020
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Enrollment Fee Allotment Authorization

Beneficiaries who currently pay by allotment from retirement pay: Your enrollment fees will continue to be paid automatically after Jan. 1, 2018. There is no further action needed. 

For beneficiaries who would like to set up a new allotment payment, complete this form.

  • Created: Dec 31, 2017
  • Modified: Dec 31, 2017
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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 hospital or clinic should complete this form to request eligibility for TRICARE Prime Remote (TPR).

If you live or work within 50 miles of a military hospital or clinic, you will generally not be eligible for TPR.

  • Created: Jan 8, 2018
  • Modified: Jan 8, 2018
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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: Dec 30, 2017
  • Modified: Dec 29, 2017
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Enrollment Exception Request

Complete this form to request an enrollment exception review.

  • Created: Jan 15, 2019
  • Modified: Jan 15, 2019
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Drive Time Waiver

A Drive Time Waiver must be signed by the beneficiary when the primary care manager (PCM) selected or assigned is farther than a 30-minute drive from the beneficiary's residence, or if the beneficiary lives outside of a Prime Service Area. By completing this form, you are waiving the drive time standards of 30 minutes for primary care and one hour for specialty care. 

Send completed forms to: 

Health Net Federal Services, LLC
PO Box 8458
Virginia Beach, VA 23450-8458
Fax: 1-844-388-8282

  • Created: Jan 7, 2019
  • Modified: Jan 7, 2019
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