Dd Form 2876 - Tricare Prime Enrollment, Disenrollment, And Primary Care Manager (Pcm)
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5OMB No. 0720-0008
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND
OMB approval expires
PRIMARY CARE MANAGER (PCM) CHANGE FORM
Feb 29, 2016
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria,
VA 22350-3100 (0720-0008). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS
BELOW.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1079 and 1086, 38 U.S.C. Chapter 17; 32 CFR 199.17; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To obtain information necessary to permit individuals to enroll, disenroll, or change their provider in TRICARE
Prime, TRICARE Prime Remote, or the Uniformed Services Family Health Plan, as requested by the individual.
ROUTINE USE(S): Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health
Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, as implemented by DoD 6025.18-R, the DoD Health
Information Privacy Regulation. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as
amended, the DoD "Blanket Routine Uses" under 5 U.S.C. 552a(b)(3) apply to this collection. A complete listing of the routine uses
permitted under 5 U.S.C. 552a(b)(3) is published at Collected
information may be shared with the Departments of Health and Human Services, Homeland Security, and Veterans Affairs, and other
Federal, State, local, or foreign government agencies, private business entities, including entities under contract with the Department of
Defense and individual providers of care, on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization
review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or criminal litigation.
DISCLOSURE: Voluntary; however, your failure to provide all the requested information may result in the denial of the request to enroll in,
transfer, or terminate your TRICARE Prime health plan coverage.
APPLICATION OPTIONS
ONLINE:
You may electronically complete, submit and print a copy of your enrollment, disenrollment or change online by logging into the Beneficiary
Web Enrollment (BWE) website at https:// The BWE website is not available to beneficiaries in overseas areas.
MAILING THE FORM:
For manual enrollment, disenrollment, or Primary Care Manager (PCM) changes in TRICARE Prime, TRICARE Prime Remote or US Family
Health Plan, complete and submit the form to the address below.
1. Forms may be mailed to the contractor identified below or, with the exception of USFHP applications, taken to a TRICARE Service
Center (TSC). Call your Contractor to determine when your new or transferred enrollment will begin.
2. For enrollment assistance, please call
at
USFHP at Pacific Medical Centers
1-888-958-7347, option 1
3. For additional information on TRICARE, visit the TRICARE website at , the Contractor's website at
or your local TRICARE Service Center (TSC).
(TMA BE&S/Contractors will add servicing contractor information. Include name, mailing address and web address of contractor, and enrollment fees.)
Uniformed Services Family Health Plan (USFHP)
WEST REGION
US Family Health Plan
at Pacific Medical Centers
PO Box 84985
Seattle WA 98124
1-888-958-7347, option 1
Page 1 of 5 Pages
DD FORM 2876, MAY 2013
REPLACES PREVIOUS EDITION AND DD FORM 2877, WHICH ARE OBSOLETE.
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