Information Collection

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

IC 5574 under ICR 201905-0720-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form
Form 2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form
Form 2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Form
2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876-1 East.docx	Form
2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876-2 West.docx	Form
2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876-3 Overseas.docx	Form

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2876-1	Yes	No	Fillable Printable
Form	2876-2	Yes	No	Fillable Printable
Form	2876-3	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: DHA-07, Military Health Information System

FR Citation: 78 FR 69076

Number of Respondents: 145,774

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	291,548	143,515	148,033
Annual IC Time Burden (Hours)	72,887	35,879	37,008
Annual IC Cost Burden (Dollars)	528,431	260,121	268,310

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.

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