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

OMB 0720-0008

These collection instruments serve as application for enrollment, disenrollment, and Primary Care Manager (PCM) Change for the Department of Defense's TRICARE Prime program. The information collected provides the necessary data to determine beneficiary eligibility, complete enrollment, change beneficiary's enrollment (new Primary Care Manager, enrolled region, add a dependent, etc.), or dis-enroll the beneficiary.

The latest form for TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change expires 2022-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 2876-1 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form Form
0720-0008_SSA_8.22.22.docx Supporting Statement A
DD Form 2876_SSN Justification.pdf Supplementary Document
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form Form
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- phone Instruction
TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change- web portal Other-Web Portal

All Historical Document Collections

202204-0720-001 Approved with change	Revision of a currently approved collection	2022-08-22
201905-0720-001 Approved with change	Extension without change of a currently approved collection	2019-05-23
201602-0720-001 Approved with change	Revision of a currently approved collection	2016-02-29
201303-0720-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-03-28
201212-0720-001 Approved without change	Revision of a currently approved collection	2012-12-07
201003-0720-001 Approved without change	Extension without change of a currently approved collection	2010-03-01
200612-0720-002 Approved without change	Extension without change of a currently approved collection	2007-01-08
200312-0720-001 Approved without change	Reinstatement without change of a previously approved collection	2003-12-19
199909-0720-001 Approved without change	Reinstatement with change of a previously approved collection	1999-09-24
199506-0720-001 Approved without change	New collection (Request for a new OMB Control Number)	1995-06-30

OMB Details

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

Federal Enterprise Architecture: Defense and National Security - Operational Defense

Form 2876-1	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Fillable Printable	Form
Form 2876-2	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Fillable Printable	Form
Form 2876-3	TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form	Fillable Printable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.