OMB No. 0720-0008
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND
OMB approval expires
PRIMARY CARE MANAGER (PCM) CHANGE FORM
May 31, 2019
The public reporting burden for this collection of information, 0720-0008, 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, at firstname.lastname@example.org. 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.
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.
You may request to enroll, disenroll or change your primary care manager (PCM) by logging into the Beneficiary Web Enrollment website
You may enroll, disenroll, or change your PCM by calling your Regional Contractor or US Family Health Plan (USFHP) at the toll-free
numbers on this page.
(3) ENROLLMENT FORM:
You may also enroll, disenroll, or change your PCM by completing and submitting the form to your Regional Contractor or USFHP at the
address or fax number below.
You will be notified of your enrollment or PCM change via email or postcard. You can then log into milConnect at:
https:// to view specific information. For additional information on TRICARE, visit the TRICARE website at
or the Regional Contractor's website at:
REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS:
International SOS Assistance, TOP Prime Enrollments, PO Box 11520, Philadelphia PA 19116
UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP):
DD FORM 2876-3, JUL 2016
Page 1 of 5 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X