Homepage / Fill in a Valid Dd 2494 1 Template
Jump Links

The DD Form 2494-1 serves a critical function in facilitating dental coverage under the Supplemental TRICARE - Active Duty Family Member Dental Plan (FMDP) for military families. This enrollment form allows sponsors to apply for dental insurance coverage specifically for their family members, ensuring they have access to essential dental care. The form is governed by the Privacy Act, requiring voluntary disclosure of information, which nonetheless is crucial for timely enrollment. There are clearly defined conditions under which the form should be completed, such as when family members reside in different locations or when the age of family members varies. It’s particularly important to ensure that the information logged in the Defense Enrollment Eligibility Reporting System (DEERS) is accurate, as this determines eligibility for benefits. Enrollees should be aware that any changes in their family status may necessitate further action to adjust their coverage. Additionally, it's emphasized that FMDP is a prepaid plan, with premium deductions occurring ahead of coverage commencement, making it essential for sponsors to understand the timing of these deductions and the potential for delays in enrollment processing. Ultimately, the DD Form 2494-1 is more than just bureaucratic paperwork; it is a vital component of ensuring the dental health and well-being of military families across the United States.

Dd 2494 1 Example

SUPPLEMENTAL TRICARE - ACTIVE DUTY FAMILY MEMBER DENTAL PLAN (FMDP)

ENROLLMENT ELECTION

 

PRIVACY ACT STATEMENT

AUTHORITY:

10 USC 55, 1076A (Dent al Plan), 5 USC 552a and EO 9397 .

PRINCIPAL PURPOSE:

Used by applicant t o apply f or dent al insurance coverage of f amily members.

ROUTINE USES:

None.

DISCLOSURE:

Volunt ary; how ever, f ailure t o f urnish all inf ormat ion could delay or prevent enrollment in t he FMDP.

CONDITIONS

This f orm should only be complet ed w hen:

(1) Family members are residing in t w o or more physically separat e locat ions, and only t he f amily members in one or more of t he locat ions are t o be enrolled; or

(2)There are no f amily members age f our (4) or older and more t han one (1) f amily member under age f our (4) and t he sponsor elect s t o enroll t he eldest f amily member; or

(3)A sponsor w it h enrolled f amily members elect s t o disenroll some, but not all, enrolled f amily members based on t he enrollment except ions list ed below .

INSTRUCTIONS

IMPORTANT: FMDP ENROLLMENT AND CLAIMS PAYMENT IS BASED UPON DEERS ELIGIBILITY FOR CHAMPUS. WHEN ENROLLING OR CHANGING FMDP ENROLLMENT, MAKE SURE YOUR DEERS INFORMATION IS CORRECT. EXPIRED ID CARDS WILL AFFECT YOUR CHAMPUS (and Dental) ELIGIBILITY. CHECK YOUR FAMILY MEMBERS' ID CARD.

NOTE: CHANGES IN FAMILY STATUS (gains and losses) THAT AFFECT YOUR DENTAL PREMIUM MUST BE REPORTED TO DEERS USING DD FORM 1172, " Applicat ion f or Unif ormed Services Ident if icat ion Card - DEERS Enrollment ."

FMDP Enrollment is f or a minimum of t w o (2) years, unless:

(1) Family members lose t heir CHAMPUS eligibilit y in DEERS; or

(2) Sponsor and f amily members t ransf er OCONUS t o an area w here FMDP is not available and t he sponsor volunt arily elect s t o disenroll all enrolled f amily members; or

(3)Sponsor and enrolled f amily members t ransf er t o a unif ormed services inst allat ion t hat of f ers space available f amily member dent al care; or

(4) Sponsor and f amily members are ret urning f rom an overseas locat ion w here FMDP is not available and t he sponsor has bet w een 12 and 23 mont hs remaining in t he unif ormed service.

A copy of the completed form must be mailed to: DEERS Support Office, ATTN: DN99, 2511 Garden Road, Monterey, CA 93940 -5330 . The DEERS Support Of f ice w ill send t he sponsor a let t er conf irming receipt and processing of t he f orm.

REMINDER: The FMDP is a " prepaid" plan, w hich means deduct ions f rom your pay must be made in advance of coverage. Coverage f or enrolled CHAMPUS eligible f amily members shall begin t he f irst day of t he mont h f ollow ing receipt of t his f orm by your personnel act ivit y. For example, if t he f orm is complet ed in January, coverage begins February 1. How ever, it is import ant t o not e t hat processing of t he enrollment inf ormat ion may t ake 30 days or more. This means t hat even t hough f amily members are eligible f or coverage, a premium deduct ion may not appear on your LES during t he f irst or second mont h of enrollment . Premium deduct ions w ill be made ret roact ive t o t he mont h t he f orm w as complet ed. It also means t hat t he cont ract or may not be able t o conf irm eligibilit y if f amily members visit a dent ist soon af t er t hey are enrolled.

Claims f or enrolled f amily members cannot be paid by t he cont ract or unt il enrollment inf ormat ion is received f rom t he government . If a claim is denied because t he cont ract or cannot verif y eligibilit y, t hat does not necessarily mean t hese services w ill not be covered. Once eligibilit y verif icat ion has been received, t he f amily member or dent ist can request reprocessing of t he denied claim by calling or w rit ing t he cont ract or.

DD FORM 2494-1, SEP 95

PREVIOUS EDITION IS OBSOLETE.

Adobe Prof essional 8 .0

SECTION I - ACTIVE DUTY MEMBER ELIGIBILITY INFORMATION

1 . SPONSOR' S NAME (LAST, First, Middle Initial)

 

2 . SPONSOR' S SOCIAL SECURITY NUMBER

3. SPONSOR' S GRADE

 

 

 

 

 

4 . SPONSOR' S UNIT

 

 

5. DATE OF EXPIRATION OF SERVICE OR

 

 

 

 

 

CONTRACT (As extended) (YYMMDD)

 

 

 

 

 

 

 

 

 

SECTION II - COVERAGE INFORMATION

 

 

 

 

 

 

 

6. ELECTION OF COVERAGE (Use additional copies of this form if needed for enrolling more family members.)

 

 

 

 

 

 

 

5

 

I have one (1) geographically separat ed f amily member f or w hom I am elect ing coverage.

 

 

 

 

 

 

 

6

 

I have more t han one (1) geographically separat ed f amily member f or w hom I am elect ing coverage.

 

 

 

 

 

 

 

 

SPONSORS WITH 12 TO 23 MONTHS RETENTION RETURNING FROM AN OCONUS AREA WHERE FMDP WAS NOT AVAILABLE:

NOTE: These enrollment codes may only be used f or sponsors enrolling f amily members ret urning f rom an OCONUS area w here FMDP w as not available. If t he f amily members did not accompany t he sponsor on t he OCONUS t our, t he sponsor may not enroll t he f amily members.

T

 

 

OCONUS Ret urnee. I have one (1) geographically separat ed f amily member f or w hom I am elect ing coverage.

 

 

 

 

U

 

 

OCONUS Ret urnee. I have more t han one (1) geographically separat ed f amily member f or w hom I am elect ing coverage.

 

 

 

 

 

List only t hose f amily members t o be enrolled in t he blocks below .

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL CURRENT ADDRESS

 

DATE OF BIRTH

 

 

NAME (Last, First, Middle Initial)

(Number, Street, City, State, ZIP Code)

 

(YYMMDD)

 

 

 

a.

b.

 

c.

 

 

 

 

 

 

 

(1)

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

 

 

 

 

 

 

 

 

 

 

 

 

 

(5)

 

 

 

 

 

 

 

 

 

 

 

 

 

(6)

 

 

 

 

 

 

 

 

 

 

 

 

7. STATEMENT OF UNDERSTANDING

 

 

 

 

 

 

 

 

 

I have checked my f amily member inf ormat ion in DEERS and verif ied t he accuracy of t he DEERS inf ormat ion.

I underst and t hat I must

complet e a new enrollment f orm if I w ant t o change t he enrollment st at us of my f amily members (such as adding family members not listed on this form). I also underst and I may not t erminat e enrollment based on a change in f amily size. If my DEERS record indicat es a f amily member is no longer eligible, a change w ill occur aut omat ically w it h no act ion on my part . I f urt her underst and t hat t he premium rat e f or t his program is subject t o change. I also underst and t hat during t he t w o year minimum enrollment period I cannot disenroll due t o a change in premium rat e. I underst and t hat enrollment in FMDP aut omat ically t erminat es t he last day of t he mont h of act ive dut y or upon terminat ion of basic pay. I aut horize payroll deduct ions t o be t aken f rom my pay based upon t he inf ormat ion in DEERS and my coverage elect ion specif ied above.

a. SPONSOR SIGNATURE

 

 

b. DATE SIGNED

 

 

 

 

(YYMMDD)

 

 

 

8 .

WITNESSING OFFICIAL (Give the sponsor a signed copy of this form.)

 

 

 

 

 

 

a.

NAME (Last, First, Middle Initial)

b. GRADE

c. SIGNATURE

d. DATE SIGNED

 

 

 

 

(YYMMDD)

 

 

 

 

 

DD Form 2494 -1 (BACK), SEP 95

File Breakdown

Fact Name Description
Authority The form is governed by 10 USC 55, 1076A and 5 USC 552a as well as Executive Order 9397.
Main Purpose This form is used by applicants to enroll their family members in the Supplemental TRICARE Active Duty Family Member Dental Plan (FMDP).
Disclosure Providing information on this form is voluntary; however, incomplete information may delay enrollment.
Conditions for Use Complete this form only under specific conditions concerning the geographical separation of family members or age exceptions.
Enrollment Duration The enrollment period lasts a minimum of two years unless certain conditions are met, such as losing eligibility.
Address for Submission Mail the completed form to DEERS Support Office, ATTN: DN99, 2511 Garden Road, Monterey, CA 93940-5330.
Premium Payments The FMDP operates as a prepaid plan; premium deductions begin before coverage starts.
Eligibility Verification Claims can only be processed once enrollment information has been verified by the government.
Impact of ID Card Expired ID cards can affect both CHAMPUS and dental eligibility; ensure family members' ID cards are current.
Previous Editions This is the DD Form 2494-1 from September 1995; earlier versions are considered obsolete.

Guide to Using Dd 2494 1

Completing the DD Form 2494-1 is an important step for enrolling family members in dental insurance coverage. After filling out the form, make sure to send a copy to the DEERS Support Office. They will confirm receipt and processing. Keep in mind that it may take some time for processing, so be patient. Here are the steps to fill out the form:

  1. Provide the sponsor's name, including last name, first name, and middle initial.
  2. Enter the sponsor's social security number.
  3. Fill in the sponsor's grade.
  4. Include the sponsor's unit.
  5. Indicate the date of expiration of service or contract in the specified format (YYMMDD).
  6. Select the election of coverage by marking one of the options that best describes the situation:
    • I have one (1) geographically separated family member for whom I am electing coverage.
    • I have more than one (1) geographically separated family member for whom I am electing coverage.
    • For sponsors returning from an OCONUS area where FMDP was not available, choose the appropriate option.
  7. List the family members to be enrolled, providing the following information for each:
    • Name (Last, First, Middle Initial).
    • Full current address.
    • Date of birth in the format (YYMMDD).
  8. Sign and date the statement of understanding, confirming that the DEERS information is accurate.
  9. Have a witnessing official fill in their name, grade, signature, and the date signed (YYMMDD).

Make sure all information is accurate before submitting the form. Errors can lead to delays or complications in obtaining coverage. Once submitted, be prepared for potential follow-up regarding your family's insurance status.

Get Answers on Dd 2494 1

What is the purpose of the DD 2494-1 form?

The DD 2494-1 form, also known as the Supplemental TRICARE - Active Duty Family Member Dental Plan (FMDP) Enrollment Election form, is primarily used for applying for dental insurance coverage for family members of an active duty service member. It allows service members to manage their family's dental insurance enrollment efficiently. Accuracy in completing this form is crucial, as it directly affects the ability to secure dental benefits for family members.

When should the DD 2494-1 form be completed?

This form should be completed under specific conditions:

  1. If family members reside in two or more physically separate locations and only some are to be enrolled in the FMDP.
  2. If there are no family members aged four or older and more than one family member is under four, allowing the sponsor to enroll the eldest family member.
  3. If a sponsor wishes to disenroll some, but not all, enrolled family members based on the exceptions detailed in the instructions.

How does the enrollment process work for the FMDP?

Enrollment in the FMDP requires that the service member accurately complete the DD 2494-1 form and submit it to the DEERS Support Office. It’s important to ensure that the information in the Defense Enrollment Eligibility Reporting System (DEERS) is correct, as this will affect eligibility for dental coverage. The family’s coverage begins on the first day of the month following the receipt of the completed form by your personnel activity. However, it is also important to note that processing this information may take up to 30 days, during which time premiums may not show up on the Leave and Earnings Statement (LES).

What happens if a family member’s dental coverage is denied after enrollment?

If a claim for dental services is denied because eligibility could not be verified, this does not necessarily mean that the services will not be covered. Once the eligibility is confirmed, either the family member or the dentist can request that the claim be reprocessed. It's crucial to maintain communication with the contractor handling the claims to ensure that any issues are resolved swiftly.

What are the financial implications of enrolling in the FMDP?

The FMDP operates as a prepaid dental insurance plan. This means that premiums are deducted from the service member’s pay in advance of coverage providing. Enrollment typically commits the service member to a minimum of two years of coverage unless specific conditions are met—such as a change in eligibility or relocation. If there are changes in family status that impact the dental premiums, these must be reported using DD Form 1172. Understanding these financial commitments is essential for planning family budgets effectively.

How can I ensure my information is accurate and up-to-date?

Before enrolling in the FMDP, it is essential for service members to verify the accuracy of their family member information in DEERS. Regular updates are necessary, especially after significant life events such as marriage, birth, or changes in residency. Keeping the DEERS record current directly impacts the eligibility for dental benefits and ensures that enrolled family members receive the coverage they need without delays or complications.

Common mistakes

Filling out the DD 2494-1 form correctly is crucial for enrolling family members in the Supplemental TRICARE Active Duty Family Member Dental Plan (FMDP). However, many individuals make mistakes that can lead to delays or complications. One common error is failing to check the accuracy of your family member’s information in the Defense Enrollment Eligibility Reporting System (DEERS). If this information is incorrect or outdated, it could prevent enrollment altogether.

Another frequent mistake involves neglecting to provide all necessary details about each family member. Individuals often think listing one family member is sufficient without realizing that additional family members require separate entries on the form. Not using extra copies of the form, when needed, can lead to incomplete submissions and processing delays.

Some sponsors forget to verify their own eligibility details, such as their grade or service expiration date. Missing or inaccurate information in this section can result in rejection of the application. Additionally, many people overlook the requirement to report any changes in family status, such as new births or changes in eligibility, to DEERS. Failing to notify DEERS of these changes can affect dental coverage.

Completing the statement of understanding section is another area where mistakes occur. Sponsors sometimes fail to read this section thoroughly, neglecting to acknowledge that enrollment must continue for a minimum period of two years. They may not understand that they cannot disenroll simply because of a change in family size or premium rates.

Missing signatures can also be a problem. Both the sponsor and the witnessing official must sign the form. Without these signatures, the submission may be deemed invalid, leading to further complications. Sponsors should also remember to provide their full current address and confirm it matches their DEERS information—another detail that can impact eligibility.

Lastly, individuals often misinterpret the instructions regarding coverage start dates. While coverage begins the first day of the month following the submission of the form, many applicants do not account for potential processing times, which can take up to 30 days. This can lead to frustration if claims are submitted too soon.

By avoiding these common mistakes, applicants can help ensure a smoother enrollment experience in the FMDP. Attention to detail and thorough understanding of the form’s requirements are essential for a successful application.

Documents used along the form

The DD Form 2494-1 is essential for enrolling family members in the Supplemental TRICARE Active Duty Family Member Dental Plan (FMDP). To facilitate this process, there are several other forms and documents that may be pertinent. Understanding these additional documents can help ensure a smooth enrollment experience.

  • DD Form 1172: This form is used to apply for a Uniformed Services Identification Card and to update enrollment in DEERS (Defense Enrollment Eligibility Reporting System). It is important when there are changes in family status that could affect eligibility for benefits.
  • DD Form 214: This document is issued upon a military member's retirement, separation, or discharge from active duty. It serves as proof of military service and may be required for various benefits and entitlements.
  • TRICARE Enrollment Application: This application is for individuals seeking TRICARE benefits for themselves or their dependents. It is crucial for ensuring family members are covered under the appropriate TRICARE plan.
  • CHAMPUS Documentation: Documentation related to the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is essential for accessing benefits. It provides necessary information for managing claims and verifying eligibility for dental and other medical services.

Each of these forms plays a role in ensuring that military families have access to the healthcare benefits they deserve. Familiarity with these documents can aid in successfully navigating the enrollment process.

Similar forms

  • DD Form 1172: Similar to the DD 2494-1 form, DD Form 1172 is used to enroll family members in the DEERS system. Both forms ensure that family members receive the appropriate benefits available to them. However, DD Form 1172 is specifically focused on obtaining or updating Uniformed Services Identification Cards rather than dental coverage.
  • DD Form 2656: This form is used for reporting the eligibility and enrollment of family members under the Survivor Benefit Plan (SBP). Like the DD 2494-1, it assesses eligibility based on family circumstances and requires accurate information to protect the sponsor’s and family members' benefits.
  • TRICARE Enrollment Form: This document is essential for TRICARE health coverage. It functions similarly to the DD 2494-1 in that it is used to enroll eligible family members in health insurance, specifically military families, thus ensuring access to needed medical care.
  • DA Form 5870: The DA Form 5870 is utilized for requesting membership in the Army’s Family Readiness Group (FRG). While this form differs in purpose, it, like the DD 2494-1, requires specific family details to ensure accurate support and communication for military families, promoting their overall well-being.

Dos and Don'ts

When filling out the DD 2494-1 form for Supplemental TRICARE, it’s important to follow some guidelines. These will help ensure your form is processed smoothly, avoiding unnecessary delays.

  • Check Your DEERS Information: Ensure that all details about you and your family members in the Defense Enrollment Eligibility Reporting System (DEERS) are correct before completing the form.
  • Fill Out All Required Sections: Make sure that every section of the form is filled out completely. Missing information can lead to processing delays.
  • Keep a Copy: Always keep a copy of the completed form for your records. This can be useful if any issues arise.
  • Follow Submission Instructions: Mail the completed form to the correct address, as outlined in the instructions. Address it specifically to the DEERS Support Office.
  • Don’t Use Outdated Information: Avoid using old details, such as expired ID card information, as this can impact eligibility.
  • Don’t Leave Sections Blank: Leaving sections incomplete may cause the form to be returned or delayed. Fill in every required field.
  • Don’t Assume Coverage Starts Immediately: Understand that processing the form may take time. Keep in mind that coverage begins the month after your form is received.
  • Don’t Forget About Changes: If there are changes in your family status, such as loss or gain of members, report them promptly. Use the DD Form 1172 to update DEERS.

By adhering to these do’s and don’ts, you can facilitate a more efficient enrollment process for the Family Member Dental Plan.

Misconceptions

  • Misconception: The DD 2494-1 form is mandatory for all TRICARE dental coverage. Many believe that this form is essential for all members seeking dental coverage. In reality, it is only necessary under specific conditions, primarily when enrolling family members who are physically separated or when the family structure changes significantly.
  • Misconception: Completing the DD 2494-1 form guarantees immediate dental coverage. Some assume that once the form is submitted, coverage will start right away. In most cases, coverage begins the first day of the month following receipt of the form, and processing can take 30 days or longer.
  • Misconception: You can disenroll family members from dental coverage anytime. Many misunderstand the rules about disenrollment. This form locks in coverage for a minimum of two years, unless certain conditions are met, such as a change in CHAMPUS eligibility or relocation to an area without access to the plan.
  • Misconception: Enrollment in this plan is free. There's often a misconception that the Family Member Dental Plan is without cost. However, it's a prepaid plan, which means deductions from the sponsor's pay will be made in advance to cover the dental insurance costs.
  • Misconception: The form can be submitted electronically. Some might think that because many forms are digital, this one can be submitted online too. It must be mailed to the DEERS Support Office, and a physical copy is required.
  • Misconception: You do not need to check DEERS before enrolling. Many overlook the importance of verifying information in the DEERS system. The enrollment relies heavily on accurate data there, and any discrepancies can delay the coverage process.
  • Misconception: All claims are automatically covered once enrolled. Some people assume that enrollment equates to immediate claims coverage. However, a contractor cannot process claims until enrollment information is verified by the government, which means some claims may be denied temporarily.
  • Misconception: You can enroll any family member at any time. It is believed that family members can be added whenever desired. However, the form has specific guidelines for eligibility and the circumstances under which family members can be enrolled or excluded.
  • Misconception: Changes in family size won’t affect coverage. Many mistakenly think that fluctuations in family members do not impact the enrollment status. However, any loss of eligibility for a family member will result in automatic adjustments based on DEERS records.

Key takeaways

Here are key takeaways regarding filling out and using the DD 2494-1 form:

  • The DD 2494-1 form is essential for applying for dental insurance coverage for family members under the Supplemental TRICARE – Active Duty Family Member Dental Plan (FMDP).
  • It is important to ensure that your DEERS (Defense Enrollment Eligibility Reporting System) information is accurate and up to date, as this affects eligibility for coverage.
  • Enrollment in the FMDP is typically for a minimum of two years. However, certain conditions, like loss of eligibility or transfer to an area where the FMDP is unavailable, may allow for disenrollment.
  • Processing your enrollment may take 30 days or more. Therefore, coverage may not start immediately even though the eligibility exists.
  • If a claim is denied due to verification issues, this does not mean the service won’t be covered. You can ask for reprocessing once eligibility is confirmed.
  • Remember that the FMDP is a prepaid plan. Premium deductions from your pay occur in advance, so ensure you keep track of your LES (Leave and Earnings Statement) to monitor these deductions.