Information Collection

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

IC 5574 under ICR 202204-0720-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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	Form
2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Car DD2876-1 DRAFT 20220419.pdf	Form
2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Car DD2876-1 DRAFT 20220419.pdf	Form
2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Car DD2876-2 DRAFT 20220419.pdf	Form
2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Car DD2876-2 DRAFT 20220419.pdf	Form
2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876-3.pdf	Form
2876-3 TRICARE Prime Enrollment, Disenrollment, and Primary Car dd2876-3.pdf	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.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2876-1	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	DD2876-1 DRAFT 20220419.pdf	Yes	No	Fillable Printable
Form	2876-2	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	DD2876-2 DRAFT 20220419.pdf	Yes	No	Fillable Printable
Form	2876-3	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	dd2876-3.pdf	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	Previously Approved
Annual Number of Responses for this IC	291,548	291,548
Annual IC Time Burden (Hours)	72,887	72,887
Annual IC Cost Burden (Dollars)	528,431	528,431

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.