Get Prime Reconsideration Request Form.doc

This guide provides clear, step-by-step instructions for completing the Prime Reconsideration Request Form online. Whether you are seeking reconsideration for a missed payment or other issues, following these detailed steps will help you navigate the process with ease.

Follow the steps to complete the Prime Reconsideration Request Form efficiently.

1. Press the ‘Get Form’ button to access the Prime Reconsideration Request Form and open it in your preferred online document editor.
2. Identify the type of request you are making by selecting either 'Reinstatement (no break in coverage)' or 'Waiver of the 12-month Lock-out (new enrollment)'. Fill in the corresponding section.
3. Provide the sponsor’s or survivor's name in the designated field, ensuring it is spelled correctly.
4. Input the date of your request using the MM/DD/YYYY format to avoid any misinterpretation.
5. Indicate your coverage type by selecting either 'Individual' or 'Family' from the available options.
6. Enter the Sponsor’s Social Security Number in the format provided (XXX-XX-XXXX).
7. Fill in your contact phone number to facilitate communication regarding your request.
8. Input your contact email address. Please note, the notification of the decision will be sent to this email.
9. Indicate whether you have previously requested reconsideration from the TRICARE Regional Office – North by selecting 'Yes' or 'No'.
10. Describe the circumstances that led to your late or missed payment in the provided space. Make sure to detail any unusual or extraordinary circumstances and add additional pages if needed.
11. Sign the form in the designated area to confirm your request. Ensure that you also provide the date of your signature.
12. Once you have completed the form, you can save your changes, download the document, print it for mailing, or share it as necessary.

Complete your Prime Reconsideration Request Form online today to ensure timely processing of your request.