TRICARE Prime Enrollment/Disenrollment Applications

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 2876 TRICARE Prime Enrollment/Disenrollment Applications	Form and Instruction	Modified	Available
Supporting Statement TRICARE PRIME.doc	Supporting Statement A	Uploaded 2010-03-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5574	TRICARE Prime Enrollment/Disenrollment Applications	Form and Instruction	Modified

ICR Details

OMB Control No: 0720-0008	ICR Reference No: 201003-0720-001
Status: Historical Active	Previous ICR Reference No: 200612-0720-002
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Prime Enrollment/Disenrollment Applications
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/20/2010
	Date Received in OIRA: 03/01/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	07/31/2010
Responses	72,905	0	72,905
Time Burden (Hours)	22,321	0	22,321
Cost Burden (Dollars)	0	0	0

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Abstract: These collection instruments serve as application for enrollment, disenrollment and Primary Care Manager (PCM) Change for the Department of Defense's TRICARE Prime program established in accordance with Title 10 U.S.C. Section 1099 (which calls for a health care enrollment system). The information collected on the TRICARE Prime Enrollment Application/PCM Change Form provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option.

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Authorizing Statute(s): US Code: 10 USC 1097a Name of Law: null
   US Code: 10 USC 1099 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 56822	11/03/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 56822	11/03/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
TRICARE Prime Enrollment/Disenrollment Applications	DD Form 2876, DD Form 2877	TRICARE Prime Enrollment Application and PCM Change Form ,   TRICARE Prime Disenrollment Applicaation

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	72,905	72,905	0	0	0	0
Annual Time Burden (Hours)	22,321	22,321	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $686,290

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/01/2010

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