u intend to join one? o Yes c No Primary Care Physician' Physician First & Last Name Address Existing Patient? o Yes o No Primary Care Dentist' Dentist First & Last Name ID# ID# — Existing Patient? r Yes III No B. Waiver of Coverage Declining Spouse's Covered COBRA Tri-Care .__ I (vie) o Other coverage d

gin currently participating one? Yes No Primary Care Physician' Existing Patient? Yes Physician Firs & Last Name No Primary Care Dentist' Dentist First & Last Name Existing Patient? Yes No Address IDS IDS Relationshipi Last Name First Name MI Sex o M 0 F Date of Birth / / Dependent Social Securi

do you intend to pin one? : ) Yes o No Primary Care Physician' Existing Patient? E Yes Physician First .6 Last Name 2 No Primary Care Dentist' Dentist First & Last Name Existing Patient? o Yes L: No IDS Address IDS — Relationship' Last Name First Name MI Sex - : M F Date of Birth / / Dependent Social