№ files_lp_4_process_3_092193
File format: docx Character count: 13689 File size: 58 KB
Official enrollment form for TRICARE Prime, TRICARE Prime Remote, TRICARE Overseas Program Prime, and Uniformed Services Family Health Plan, including instructions for enrollment, disenrollment, and primary care manager changes.
Year: 2016
Region: United States and Overseas
Subject: Health Care Enrollment and Management
Document Type: Government Form
Agency: Department of Defense
Author: Defense Health Agency
Intended Audience: Active duty service members, retirees, and eligible family members
Effective Period: Ongoing until updated
Approval: OMB No. XXXX-XXXX
Previous Edition: Obsolete
Form Number: DD Form 2876-3
Application Methods: Online, Telephone, Paper Submission
Privacy Regulations: HIPAA, 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17
Price: 8 / 10 USD
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RBI Notifications on International Banking and Finance: IIBX PCM Membership, Interest Equalization Scheme Extension, Gold Import Guidelines, and FPI Debt Investment Limits (April–June 2022)
Year: 2022
Issuing Authority: Reserve Bank of India
Department: Department of Regulation; Foreign Exchange Department
Reference Numbers: RBI/2022-23/62; RBI/2022-23/60; RBI/2022-2023/57; RBI/2022-23/28
Dates of Issue: April 19, 2022; May 25, 2022; May 31, 2022; June 07, 2022
Region: India
Sector: Banking and Financial Regulation
Legal Basis: Banking Regulation Act, 1949; Foreign Trade (Development and Regulation) Act, 1992; Foreign Exchange Management Act, 1999; Foreign Exchange Management (Debt Instruments) Regulations, 2019
Subject: Professional Clearing Membership of India International Bullion Exchange IFSC Limited; Interest Equalization Scheme on Export Credit; Import of Gold by Qualified Jewellers; FPI Investment Limits in Debt and Credit Default Swaps
Addressees: Scheduled Commercial Banks; Authorised Dealer Category-I Banks; Small Finance Banks; Cooperative Banks; Exim Bank; Authorized Persons
Geographical Scope: GIFT-IFSC, India
Effective Period: Financial Year 2022–23 (including provisions effective from October 1, 2021)
DHSS Program Management Interface Control Document Describing the TRICARE Dental Program (TDP) to MDR Data Exchange Mod 2 Approved Version June 7, 2012
Year: 2012
Region / City: Falls Church, VA
Topic: TRICARE Dental Program, Data Exchange
Document Type: Interface Control Document (ICD)
Organization / Institution: DHSS Program Executive Office
Author: Not specified
Target Audience: DHSS Program Executive Office, TMA Contract Operations Office
Period of Validity: Ongoing
Approval Date: June 7, 2012
Date of Changes: May 25, 2012
Autism Care Demonstration Program Changes: An Overview of What TRICARE Beneficiaries Needs to Know WebinarTranscript
Year: 2026
Region / City: United States
Theme: Healthcare, Autism Care
Document Type: Webinar Transcript
Organization: Defense Health Agency
Author: Christina Piechoski, Dr. Amy Serda, Dr. Krystyna Bienia
Target Audience: TRICARE beneficiaries, families, healthcare professionals
Effective Period: From July 25, 2014
Approval Date: Not specified
Date of Changes: 2026
Document Status: Public Announcement
Consumer Choice Form for Mental Health Rehabilitation Services (MHRS) Core Service Agency Enrollment, Transfer, and Disenrollment
Year: Not specified
Region / City: District of Columbia
Topic: Mental Health Services
Document Type: Form
Organization / Institution: Government of the District of Columbia, Department of Behavioral Health
Author: Not specified
Target Audience: Adults seeking Mental Health Rehabilitation Services
Effective Period: Not specified
Approval Date: Not specified
Modification Date: Not specified
Family Care, PACE, Partnership, and IRIS Program Requested Disenrollment
Year: 2025
Region / City: Wisconsin
Topic: Health Services
Document Type: Form
Organization: Department of Health Services, Division of Public Health
Author: Department of Health Services
Target Audience: Managed Care Organizations, IRIS Consultant Agencies, PACE Organizations, Bureau of Quality & Oversight
Period of Effectiveness: N/A
Approval Date: N/A
Amendment Date: N/A
Contextual Description: Form used by organizations to request disenrollment from the Family Care, PACE, Partnership, and IRIS programs in Wisconsin.
Waiver Program Disenrollment Request
Year: 2023
Region / City: New Jersey
Topic: Disenrollment from DDD Programs
Document Type: Request Form
Institution: Division of Developmental Disabilities (DDD)
Author: DDD Support Coordinator
Target Audience: Individuals enrolled in DDD programs, legal guardians, DDD staff
Effective Period: Not specified
Approval Date: Not specified
Date of Modifications: Not specified
Qualified Health Home Lead Requested Disenrollment – Involuntary
Year: Not specified
Region / City: Not specified
Subject: Involuntary disenrollment from the Health Home program
Document Type: Procedure/Guideline
Organization / Institution: Not specified
Author: Not specified
Target Audience: Health Home Care Coordinators, Lead
Effective Period: Not specified
Approval Date: Not specified
Date of Changes: Not specified
Contextual Description: Procedure for handling involuntary disenrollment from the Health Home program due to beneficiary behaviors or environmental concerns.
IRIS Involuntary Disenrollment Request Form (F-01319, 02/2017)
Country: United States
State: Wisconsin
Issuing Body: Department of Health Services, Division of Medicaid Services
Program: IRIS (Include, Respect, I Self-Direct)
Form Number: F-01319
Edition Date: 02/2017
Document Type: Administrative request form
Subject: Involuntary disenrollment of IRIS participants
Legal Reference: Wisconsin State Statute; IRIS Work Instruction Manual Section 7.1A.1
Target Group: IRIS Consultant Agencies (ICAs)
Applicable Reasons for Disenrollment: No Spend; No Contact; Health and Safety; Residing in an Ineligible Living Setting; Substantiated Fraud; Mismanagement of Budget Authority; Mismanagement of Employer Authority; Refusal to Comply with IRIS Program Requirements
Sections: Demographics; Reason for Request; Explanation of Attempted Mitigation Strategies; Conclusion; Applicable to No Contact or No Spend Only
Signature Requirement: IRIS Consultant Agency Representative
Personal Data: Participant’s name, MCI, contact history, expenditure information
Topics: PCM TRICARE Disenrollment