TRICARE PRIME REMOTE (TPR)
Determination of Eligibility Enrollment Request Form

Who is eligible?  Only Active Duty Service Members (ADSMs) are eligible to request Eligibility Enrollment requirements for TPR Enrollment.  Exceptions will only be granted if they meet the eligibility criteria in the TRICARE Operations Manual, Chapter 16, Section 1, Para 3.0

ADSMs/NG/RC 180 Pre-Mobilization who both LIVE and WORK more than 50 miles, or approximately more than a one hour drive, from a military treatment facility (MTF) may be eligible to enroll in TPR.

* Required
Date of Request
11/21/2014
Beneficiary Status *
Rank (SGT/E5) *

Service *
Sponsor's Name (Last, First) *
Address w/ Zip (Home)
Street: *
City: *
State: *
Zip: *
Phone Number/E-Mail
(H) *
(W) *
E-Mail *
Unit Name *
Work Address w/ Zip
Street: *
City: *
State: *
Zip: *
Unit Phone Number
Drive time (in minutes) from Work to nearest MTF:
Drive time (in minutes) from Home to nearest MTF:
Name and Location of nearest MTF:
Name: *
Street: *
City: *
State: *
Zip: *

Reason for Determination Request:


Additional Comments:

Rank/Name of Unit Command (or Designee): *

Unit Commander Address *
Unit Commander Phone *
Unit Commander E-Mail *
Questions? Call (866) 307-9749
Thank you.  TPR Determination of Eligibility Enrollment Request Form has been submitted successfully.