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

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

OMB: 0720-0008

IC ID: 5574

Information Collection (IC) Details

View Information Collection (IC)

TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
32 CFR 199.17

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form dd2876-1 East.docx Yes No Fillable Printable
Form 2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form dd2876-2 West.docx Yes No Fillable Printable
Form 2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form dd2876-3 Overseas.docx Yes No Fillable Printable

Defense and National Security Operational Defense

DHA-07, Military Health Information System  78 FR 69076

145,774 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 291,548 0 0 143,515 0 148,033
Annual IC Time Burden (Hours) 72,887 0 0 35,879 0 37,008
Annual IC Cost Burden (Dollars) 528,431 0 0 260,121 0 268,310

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