Military care waiver form 2026

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The document is an Access to Care Waiver Form for TRICARE Prime and Young Adult Prime (TYA) programs. It requires the identification of the sponsor and young adult, along with their Social Security Numbers. The form includes a waiver statement acknowledging that if the selected Primary Care Manager (PCM) is more than a 30-minute drive from the residence or outside the Prime Service Area, the applicant agrees to waive both primary and specialty care access standards. It concludes with instructions for mailing or faxing the completed form and includes a Privacy Act statement.

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Click ‘Get Form’ to open the military care waiver form in the editor.
Select your TRICARE Program from the options provided: Prime or Young Adult Prime (TYA). This selection is crucial for determining your coverage.
Identify the Sponsor for Prime or Young Adult for TYA by filling in their name and Social Security Number (SSN) in the designated fields.
Next, enter the Young Adult's name and SSN. Ensure that all information is accurate to avoid processing delays.
Read through the Access to Care Waiver Statement carefully. Acknowledge your understanding by signing in the provided space, along with the date.
Finally, mail or fax the completed form to Humana Military using the address and fax number listed at the bottom of the form.

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