Form Information

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FORM NUMBER:

DD2876

TITLE:

TRICARE PRIME ENROLLMENT, DISENROLLMENT AND PRIMARY CARE

MANAGER (PCM) CHANGE FORM

EDITION DATE:

20130101

CANCELLATION DATE:

FORMATS:

PLEASE BE ADVISED:

No link under "FORMATS:" indicates no electronic format is available.

To obtain copies of forms, contact YOUR Military Service or Component

Forms Manager

click here.

Cancelled forms are not available.

REMARKS:

Obtain the DD Form 2876 from http://www.tricare.mil/forms or your TRICARE

Regional Contractor's website.

ISSUANCES:

32 CFR 199.17(o)(3)

SPONSOR / POC:

HA

SUB-SPONSOR:

NUMBER OF PAGES:

5

USERS*:

A N AF

PRESCRIBED OR ADOPTED?:

P

DISPOSITION:

O

SUBJECT GROUP:

6010

FORM CONTROLLED:

N

MANDATORY PRINT SPECIFICATIONS:

N

RCS:

IRCN:

OMB:

0720-0008

PRIVACY ACT IMPLICATIONS:

Y

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* All revisions and/or cancellations must be coordinated through these USERS.

DISPOSITION: S = Do NOT use previous edition. U = Use previous edition until supply is depleted.