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Submission for OMB Review; Comment Request




The Department of Defense has submitted to OMB for clearance, the following proposal for collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. Chapter 35).

DATES: Back to Top

Consideration will be given to all comments received by June 1, 2010.

Title and OMB Number: TRICARE Prime Enrollment Application/PCM Change Form DD Form 2876, and TRICARE Prime Disenrollment Application; DD Form 2877; OMB Number 0720-0008.

Type of Request: Extension.

Number of Respondents: 72,905.

Responses per Respondent: 1.

Annual Responses: 72,905.

Average Burden per Response: 18.367 minutes (average).

Annual Burden Hours: 22,317 hours.

Needs and Uses: This information is collected in accordance with the National Defense Authorization Act for Fiscal Year 2001 (Pub. L. 106-398), section 723(b)(E)). These collection instruments serve as applications for the Enrollment, Primary Care Manager (PCM) Change and Disenrollment for the Department of Defense's TRICARE Prime program established in accordance with title 10 U.S.C. 1099 (which calls for a healthcare enrollment system). Monthly payment options for retiree enrollment fees for TRICARE Prime are established in accordance with title 10 U.S.C. 1097a(c). The information collected on the TRICARE Prime Enrollment Application/PCM Change Form provides the necessary data to determine beneficiary eligibility, to identify the selection of a health care option, and to change the designated PCM when the beneficiary is relocating or merely requests a local PCM change. The information collected on the TRICARE Prime Disenrollment Form provides the necessary data to disenroll a beneficiary from TRICARE Prime. The Disenrollment Application is needed to implement disenrollment from TRICARE Prime, TRICARE Prime Remote or the Uniformed Services Family Health Plan as requested by the enrollee. Failure to provide information will result in continued enrollment and beneficiaries' responsibility for payment of an enrollment fee.

Affected Public: Individuals or households.

Frequency: On occasion.

Respondent's Obligation: Required to obtain or retain benefits.

OMB Desk Officer: Mr. John Kraemer.

Written comments and recommendations on the proposed information collection should be sent to Mr. Kraemer at the Office of Management and Budget, Desk Officer for DoD, Room 10236, New Executive Office Building, Washington, DC 20503.

You may also submit comments, identified by docket number and title, by the following method:

Instructions: All submissions received must include the agency name, docket number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at as they are received without change, including any personal identifiers or contact information.

DOD Clearance Officer: Ms. Patricia Toppings.

Written requests for copies of the information collection proposal should be sent to Ms. Toppings at WHS/ESD/Information Management Division, 1777 North Kent Street, RPN, Suite 11000, Arlington, VA 22209-2133.

Dated: April 26, 2010.

Mitchell S. Bryman,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 2010-10005 Filed 4-28-10; 8:45 am]


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