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DoD Forms Management Program

FORM INFORMATION

Form Number: DD 2896-1

Title: Reserve Component Health Coverage Request

Edition Date: 7/1/2010

For use of this form please contact: The Defense Health Agency (DHA)

This form must be completed electronically via the Beneficiary Web Enrollment Portal: https://milconnect.dmdc.osd.mil/milconnect/public/faq/Medical_Benefits-BWE

If unable to access the form via the portal, contact the DEERS Support Office.