reconsideration request form - TRICARE Overseas

TRICARE Young Adult (TYA)Request for TRICARE Regional Office Reconsideration of Involuntary Disenrollment,Late Initial Enrollment and Late Changes to CoverageSection I. Sponsor / Beneficiary informationTYA Sponsor Name: _________________________________________________________DEERS Family ID / SSN: _________________________________________________________Mailing Address: _________________________________________________________City, State, ZIP: _________________________________________________________Daytime Phone Number: __________________ E-mail: _________________________________Date of Request: ___ / ___ / ___TYA Beneficiary Name: _________________________________________________________DEERS Family ID / SSN: _________________________________________________________Section II. Reconsideration Request DetailsRequest Reconsideration of (Check One):Involuntary DisenrollmentLate Initial EnrollmentLate change to coverage due to qualifying life eventSponsor’s Unit: ___________________________________________________________________Unit Address & Phone Number:_____________________________________________________Unit Administrative Officer/Contact & Phone Number: _________________________________Please provide details regarding your request for reconsideration (attach additional pages as necessary):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section III. Sponsor SignatureBy signing this form, you are authorizing International SOS Assistance Inc., to process the request as completed above.___________________________________________Signature________________________Date________________________________________Print NameSection IV. TRO Use OnlyApprovedNot Approved – Reason:_________________________________Signature of Approving Authority: _____________________________Date: ___________________(cont.)

TRICARE Young Adult (TYA)Request for TRICARE Regional Office Reconsideration of Involuntary Disenrollment,Late Initial Enrollment and Late Changes to CoverageForm InstructionsUse this form if you would like to request re-enrollment into the TYA Overseas Program following an involuntarydisenrollment, late initial enrollment, or late change to coverage due to qualifying life event (QLE). Forms will be sent tothe TRICARE Regional Office for review within 10 days of receipt. Please see instructions below on how to submit form.Section I. – Sponsor / Beneficiary InformationComplete TYA Sponsor and Beneficiary personal information. Please do not leave anything blank. Please provide aphone number where we can reach you if we need your assistance in processing the information you provided on thisform.Section II. – Reconsideration Request DetailsIndicate the request type (involuntary disenrollment, late initial enrollment or late change to coverage due to QLE) andcomplete all sections with required information. Please do not leave anything blank.Section III. Authorized signatureHow to Submit Form:Submit a completed copy of page 1 of this form via one of the options below:Mail to:International SOS Assistance, Inc.Attention: TOP TRS/TRR/TYA EnrollmentsPO Box 11689Philadelphia, PA 19116Fax to: +1-215-354-5015PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C. 1079 and 1086, 32 U.S.C. Chapter 17; 32 CFR 199.17; 45 CFR Parts 160 and 164, HealthInsurance Portability and Accountability Act (HIPAA) Privacy and Security Rules; and E.O. 9397 (SSN), as amended.PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to be re-enrolled into the TYAOverseas Program.ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of1974, as amended, these records may specifically be disclosed outside the Department of Defense as a routine usepursuant to 5 U.S.C. 552a(b)(3) as follows: to the Departments of Health and Human Services, Homeland Security, andVeterans Affairs, and to other Federal, State, local, or foreign government agencies, and to private business entities,including entities under contract with the Department of Defense and individual providers of care, on matters relating toeligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, programintegrity, third-party liability, coordination of benefits, and civil or criminal litigation.DISCLOSURE: Voluntary; however, failure to provide information may result in the denial of re-enrollment into theTYA Overseas Program and cancellation of coverage.