TRICARE PRIME ENROLLMENT APPLICATION AND
PCM CHANGE FORM
OMB No. 0720-0008
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Expires Jan 31, 2007
Instructions before completing this form.)
AGENCY DISCLOSURE NOTICE
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, Executive Services and Communications Directorate
(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 APPLICATION TO THE ABOVE
SEND YOUR APPLICATION TO THE ADDRESS SHOWN ON THE
APPLICATION INSTRUCTION SHEET.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 552a, 10 U.S.C. 1079 and 1086, 58 FR 45318, 65 FR 30966,
PRINCIPAL PURPOSE(S): To evaluate eligibility for medical care provided by civilian
sources to Military Health Services System beneficiaries applying for coverage under the
TRICARE Program (32 CFR 199.17).
ROUTINE USE(S): Information from application forms and related documents may be given
to the Department of Health and Human Services, and/or the Department of Transportation
consistent with their statutory administrative responsibilities under TRICARE; to the
Department of Justice for representation of the Secretary of Defense in civil actions.
Appropriate disclosures may be made to other Federal, State, local, and foreign
government agencies, private business entities, and individual providers of care, on matters
relating to entitlement, fraud, program abuse, program integrity, and civil and criminal
litigation related to the operation of the TRICARE Program.
DISCLOSURE: Voluntary; however, failure to provide information will result in the denial of
DD FORM 2876, MAR 2004
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