Form Information

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FORM NUMBER:

DD2877

TITLE:

TRICARE PRIME DISENROLLMENT APPLICATION

EDITION DATE:

20110201

CANCELLATION DATE:

20130103

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:

This form is no longer needed and can be cancelled. "Disenrollment" was

incorporated into the new DD Form 2876, TRICARE Prime Enrollment,

Disenrollment and PCM Change Form.

ISSUANCES:

SPONSOR / POC:

HA

SUB-SPONSOR:

NUMBER OF PAGES:

4

USERS*:

A N AF

PRESCRIBED OR ADOPTED?:

P

DISPOSITION:

O

SUBJECT GROUP:

6010

FORM CONTROLLED:

N

MANDATORY PRINT SPECIFICATIONS:

N

RCS:

IRCN:

OMB:

0702-0008

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.