View Information Collection (IC)

View Information Collection (IC)

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:

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

Federal Enterprise Architecture Business Reference Module

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 %

	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

Documents for IC

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.