Information Collection

TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form

IC 5574 under ICR 201602-0720-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form DD 2876 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form and Instruction
0720-0008 - BWE Screenshots.pdf www.dmdc.osd.mil/appj/bwe/indexAction.do	Other-Web Portal
DD 2876 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876_20160226.PDF	Form and Instruction

IC Title:

TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DD 2876	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	dd2876_20160226.PDF		Yes	No	Fillable Printable
Other-Web Portal			0720-0008 - BWE Screenshots.pdf	https://www.dmdc.osd.mil/appj/bwe/indexAction.do	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: DHA-07

FR Citation: 78 FR 69076

Number of Respondents: 148,033

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	148,033	75,128	72,905
Annual IC Time Burden (Hours)	37,008	14,691	22,317
Annual IC Cost Burden (Dollars)	268,310	268,310	0

Documents for IC

table that charts IC Documents
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.