TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CARE MANAGER (PCM) CHANGE FORM

ICR 201303-0720-001

OMB: 0720-0008

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2013-03-28
Justification for No Material/Nonsubstantive Change
2013-03-28
Supporting Statement A
2012-12-07
ICR Details
0720-0008 201303-0720-001
Historical Active 201212-0720-001
DOD/DODOASHA
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CARE MANAGER (PCM) CHANGE FORM
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 05/14/2013
Retrieve Notice of Action (NOA) 03/28/2013
  Inventory as of this Action Requested Previously Approved
02/29/2016 02/29/2016 02/29/2016
72,905 0 72,905
22,317 0 22,317
0 0 0

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 provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option.

US Code: 10 USC 1097a Name of Law: null
   US Code: 10 USC 1099 Name of Law: null
  
None

Not associated with rulemaking

  74 FR 56822 11/03/2009
77 FR 56822 11/21/2012
No

  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) 22,317 22,317 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Slight decrease due to recalculation of burden.

$686,290
No
No
No
No
No
Uncollected
Patricia Toppings 703 696-5284 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/28/2013


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