Information Collection

TRICARE Prime Enrollment/Disenrollment Applications

IC 5574 under ICR 200612-0720-002 · OMB 0720-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0008 can be found here:

Documents and Forms

Document Name Document Type
Form DD Form 2877 TRICARE Prime Enrollment/Disenrollment Applications Form and Instruction
Enrollment Screen Views.pdf Other-Enrollment Screen Views
Disenrollment Screen Views.doc Other-Disenrollment Screen Views
DD Form 2876 TRICARE Prime Enrollment Application and PCM Change Form dd2876.pdf Form and Instruction
DD Form 2877 TRICARE Prime Disenrollment Applicaation dd2877.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE Prime Enrollment/Disenrollment Applications	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.17

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DD Form 2877	TRICARE Prime Disenrollment Applicaation	dd2877.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	DD Form 2876	TRICARE Prime Enrollment Application and PCM Change Form	dd2876.pdf	Yes	Yes	Fillable Fileable
Other-Enrollment Screen Views			Enrollment Screen Views.pdf	Yes	Yes	Fillable Fileable
Other-Disenrollment Screen Views			Disenrollment Screen Views.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 72,905	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	72,905	52,216	20,689
Annual IC Time Burden (Hours)	22,321	20,171	2,150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.