Determination of Eligibility Enrollment Request Form

Who is eligible?  Only Active Duty Service Members (ADSMs) are eligible to request Waiver of Eligibility requirements for TPR Enrollment.  Exceptions will only be granted if they meet the eligibility criteria in the TRICARE Operations Manual (TOM), Chapter 17, Section 1, Para 2.3 through 2.4.  See

ADSMs 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
Beneficiary Status *

(if other, write in response)
Rank *

Service *
Sponsor's Name (Last, First) *
Address w/ Zip (Home) *
Phone Number/E-Mail
(H) *
(W) *
E-Mail *
Unit Name
Unit Address w/ 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:

Reason for Waiver Request:

Additional Comments:

Signature of Requestor: (Print name if sending via online form) *

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

Unit Commander Address *
Unit Commander Phone *
Unit Commander E-Mail *

Questions? Call (619) 236-5312 or E-Mail

Send by Fax (619) 231-4245