Enrollment Application Instructions
Page-by-page guide to the enrollment application form
Page 1: Title Page. This is the “TRICARE Prime Enrollment Application and Primary Care Manager (PCM) Change Form” issued by the Department of Defense. Since US Family Health Plan is a TRICARE Prime option, this is the correct form to use if you want to enroll with us. (Don’t worry, there are just a few pages that need to be filled out. The form itself is only 4 pages – it actually begins on page 4.)
PCM = PCP. The term “PCM” stands for Primary Care Manager. At US Family Health Plan, we use the term “PCP” – or Primary Care Provider. Your PCP is the doctor you call when you need health care. You can choose your PCP from our Provider Directory – there’s a place on the enrollment form to indicate your choice.
Page 2: General Instructions. #1 and #2 are not applicable. Clarification of #3. US Family Health Plan is headquartered in Boston, MA. Our large civilian network of doctors and hospitals serves members who live in Massachusetts, Rhode Island, and portions of southern New Hampshire and north-central Connecticut.
Page 3: Mailing Instructions. These instructions are not applicable since you are enrolling with US Family Health Plan. The completed form should be mailed to: US Family Health Plan, Attn: Enrollment, PO Box 9195, Watertown, MA 02471-9900. Be sure to keep a copy for your records. You may also fax the form to us at 617-562-5234.
Pay Instructions. There are no enrollment fees for active-duty family members. There are no enrollment fees for individuals with Medicare Part B. For everyone else, enrollment fees apply – and only those people need to complete Section VII on the form.
Page 4: The application starts here: it’s a 4-page form. Please print in ink. Where there are check-boxes, check the box in front of your selection/response. For example, check the box in front of US Family Health Plan Enrollment.
Primary Care Manager Preferences (Line #13). Instead of merely indicating your preferences in a PCM, you can actually choose your Primary Care Provider (PCP). Visit Find A Doctor to search for primary care providers near you. Then, simply print the name of the doctor you choose to be your Primary Care Provider (PCP) on line 13a. Your family members should indicate their PCP choices on page 5. [Once you’ve chosen your PCP(s), there’s no need to further describe your preferences – so there’s no need to fill out the other lines relating to specialty and gender.
Page 5: Section II. Enrolling family members’ information is entered here. If more than three family members are enrolling, please fill out additional copies of page 5.
Page 6: Section III. Retirees and their family members should read both questions carefully and indicate your responses. Active-duty families can skip this section and proceed to Section VI to sign and date the enrollment application.
Section IV and V. Skip these sections; they are not applicable.
Section VI: Signature. Sign and date your application on the bottom line of page 6.
Page 7: Section VII: Payment of Enrollment Fees. In the instructions for this section state that Medicare-eligible members must be enrolled in Medicare Part B to be eligible for enrollment in TRICARE Prime. This is not the case for enrollment in US Family Health Plan. Medicare Part B is not required to enroll in US Family Health Plan, but it is strongly recommended. If you have Medicare Part B, your enrollment fee is waived and there are no co-payments, except for prescriptions. In the event that you have Medicare Part B and your spouse does not, you would pay just one enrollment fee (for your spouse).
Questions? Call 1-888-815-5510 during business hours. We can provide any assistance you may need.