Dear Mr./Mrs. The enclosed "Former Spouse Information/Application ...

Former Spouse Information/Application Packet Page 2If you satisfy these criteria, you will continue to be eligible for medical benefits only. You willcontinue to be eligible for these benefits as long as you do not remarry or acquire employersponsored health insurance. You are required to notify this office if there is any change in yourstatus. You are not eligible for commissary, exchange, or theater privileges.Category 3 - 20/20/15 (Post 4/1/85) Unremarried Former Spouse (URFS04)To qualify for benefits in this category you must meet the following criteria:1. You must be the former spouse of a member who performed 20 years of active servicecreditable towards determining the member's eligibility for retirement and must have beenmarried to that member for 20 years;2. Fifteen of the twenty years of marriage must have been concurrent with the member'sactive service;3. You must not be participating in any employer-sponsored health or medical insurance; and4. You must not be remarried since being divorced from the member and your divorce musthave been final on or after April 1, 1985.If you meet these criteria, you are eligible for medical care only under USHBP for a period ofone year starting on the effective date of your divorce from the PHS officer. If you qualify forbenefits in this category, you will lose your eligibility for medical benefits one year after theeffective date of your divorce. After one year you will be eligible to purchase a temporaryindividual health insurance policy under the Continued Health Care Benefit Program (CHCBP).Unremarried former spouses are eligible for 36 months of health insurance coverage underCHCBP. CHCBP is a self-pay program for individuals who lose their eligibility for UniformedServices medical benefits. After the expiration of the CHCBP policy, a former spouse hassole responsibility for obtaining health coverage.Before we can find you eligible for any of these benefits and privileges, we must first determinethat:1. Your former spouse served 20 years of active service creditable towards retirementeligibility;2. You and your former spouse were married for at least 20 years;3. You are still unremarried;4. You do not participate in an employer-sponsored health insurance program; and5. Your divorce decree is final.

Former Spouse Information/Application Packet Page 3To make these determinations we ask that you send us the following:1. A copy of your marriage certificate;2. A copy of the final divorce decree;3. A completed certification sheet with your signature (keeping a copy for your records); and4. A completed Form DD-1172, "Application for Uniformed Services Identification andPrivilege Card," (keeping a copy for your records).If your eligibility for benefits is verified by these documents, you will be issued a UniformedServices Identification and Privilege Card (ID card) which will show the benefits to which you areentitled. If you qualify as a URFS02 (20-20-20), you may use the identification card for allbenefits as you did while married to your former spouse.If you qualify as a URFS04 (post 4/1/85 20-20-15), you will be issued an ID card which will showthat you are eligible for medical benefits only and not eligible for commissary and exchangeprivileges.If you qualify as a URFS02 or URFS03, your ID card will be issued for 4 years, or until your 65thbirthday, whichever is earliest. If you qualify as a URFS04 your card will be issued for 1 yearfrom the effective date of your final divorce decree or until your 65th birthday, whichever isearliest.Your medical benefits will include use of all Uniformed Services medical treatment facilities.You will also be eligible for benefits under TRICARE (formerly the Civilian Health and MedicalProgram for the Uniformed Services (CHAMPUS)) until you reach age 65.We must review the requested documents and find you eligible for benefits before we canauthorize the issuance of an ID card to you.Please send the documents requested above to:Division of Commissioned Corps Officer Support, OCCOAttn: DEERS1101 Wootton Parkway, PL, Ste 100Rockville, MD 20857If you have any questions or need assistance please call this office at (240) 453-6131.Enclosures

PHS FORMER SPOUSE'S CERTIFICATION OF ELIGIBILITYThis document must be signed by all former spouses of PHS commissioned officers who haveapplied for issuance of Uniformed Services Identification and Privilege Cards (ID card) underthe provisions of the Former Spouses' Protection Act (Public Law 97-252 as amended).I, _______________________, acknowledge that I have been informed of the conditions underwhich I may be issued an ID card and that I must meet the following criteria in order to beeligible for issuance of an ID card based on the service of_______________________, a retiredcommissioned officer of the U.S. Public Health Service, who is my former spouse.1. I was married to the officer named above for at least 20 years.2. My divorce from the officer named above is final and there is no appeal of the divorcepending.3. I have not married since my divorce from the officer named above has become final.4. I do / do not participate in a health insurance program sponsored by myemployer.5. I will notify the Division of Commissioned Corps Officer Support, 1101 WoottonParkway, PL, Ste. 100, Rockville, MD 20852 immediately, in writing, if I remarry orenroll in a health insurance program sponsored by my employer.6. I understand that only the Division of Commissioned Corps Officer Support has theauthority to approve my application for an ID card under the Former Spouses' ProtectionAct.7. I will provide the Division of Commissioned Corps Officer Support with a current addressthrough which I may be contacted during the period that I remain eligible for thesebenefits.8. If I provide false information in making this application I can be prosecuted for fraudagainst the U.S. Government, and may be subject to fine or imprisonment or both.______________________________________Signature_______________________DatePlease return this signed certification to:Division of Commissioned Corps Officer Support, OCCOAttn: DEERS1101 Wootton Parkway, PL, Ste 100Rockville, MD 20857