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OMB No. 0720-0008
OMB approval expires
20250930
TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND
PRIMARY CARE MANAGER (PCM) CHANGE FORM
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, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@ mail.mil. 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.
PRIVACY ACT STATEMENT
AUTHORITY: U.S.C. App. 3, Inspector General Act of 1978; 5 U.S.C. Chapter 90, Federal Long-Term Care Insurance; 10 U.S.C. 136, Under Secretary of Defense for Personnel
and Readiness; 10 U.S.C. Chapter 53, Miscellaneous Rights and Benefits; 10 U.S.C. Chapter 54, Commissary and Exchange Benefits; 10 U.S.C. Chapter 58, Benefits and
Services for Members being Separated or Recently Separated; 10 U.S.C. Chapter 75, Deceased Personnel; 10 U.S.C. 2358, Research and Development Projects; DoD Directive
1000.25, DoD Personnel Identity Protection (PIP) Program; DoD Instruction 1015.9, Professional United States Scouting Organization Operations at United States Military
Installations Located Overseas; DoD Instruction 1341.2, Defense Enrollment Eligibility Reporting System (DEERS) Procedures; DoD Manual 1341.02, DoD Identity Management
DoD Self-Service (DS) Logon Program and Credential; and E.O. 9397 (SSN), as amended.10 U.S.C. 113, Secretary of Defense; 5 U.S.C. 552, Freedom of Information Act, as
amended; 5 U.S.C. 552a, Privacy Act of 1974, as amended; 32 CFR part 286, DoD Freedom of Information Act (FOIA) Program; 32 CFR part 310, Protection of Privacy and
Access and Amendment of Individual Records Under the Privacy Act of 1974; DoD Directive, 5400.07, DoD Freedom of Information Act (FOIA) Program; DoD Instruction 5400.11,
DoD Privacy and Civil Liberties Programs; DoD Manual 5400.07, DoD Freedom of Information Act (FOIA) Program; DoD 5400.11-R, DoD Privacy Program; and Executive Order
9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): The DD Form 2876 will be used to obtain information necessary to permit individuals to enroll, disenroll, or change their provider in TRICARE Prime
Overseas or TRICARE Prime Remote Overseas, as requested by the individual.
ROUTINE USE(S): These records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to the Federal agencies and/or their
contractors, the Transportation Security Administration and other federal transportation agencies, for purposes of authenticating the identity of individuals; to validate demographic
data; the Social Security Administration; and Veterans Benefits Administration, DVA their statutory administrative responsibilities; to Federal, State, local, or foreign governmental
agencies and to private business entities related to eligibility, To consumer reporting agencies, third-party liability, benefits, and litigation related to TRICARE’s operation; To the
CMS, HHS, for the purpose of verifying individual's healthcare eligibility status, in accordance with the Affordable Care Act; to each of the fifty states and the District of Columbia.
For further information regarding routine uses, refer to the applicable SORN hyperlinked below. Any protected health information (PHI) in your records may be used and disclosed
generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare
operations. In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed
outside the DoD as a routine use to private physicians and federal agencies to include 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. DoD’s Routine Use disclosures are limited to those explicitly stated in each SORN. For a full listing of the Routine Uses, refer
to below applicable SORNs hyperlinked below. Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules as
implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.
APPLICABLE SORN: Defense Manpower Data Center (DMDC) 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS) (May 31, 2022; 87 FR 32384. https://
www.federalregister.gov/documents/2022/05/31/2022-11610/privacy-act-of-1974-system-of-records
DISCLOSURE: Voluntary. If you choose not to provide the requested information, there may be an administrative delay processing your request and the DoD may be unable to
process it; however, no penalty will be imposed.
APPLICATION OPTIONS
(1) ONLINE:
You may request to enroll, disenroll or change your primary care manager (PCM) by logging into the Beneficiary Web Enrollment website
at https://milconnect.dmdc.osd.mil
(2) TELEPHONE:
You may enroll, disenroll, or change your PCM by calling your Regional Contractor 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 at the address or fax
number below.
(4) NOTES:
You will be notified of your enrollment or PCM change via email or postcard. You can then log into milConnect at: https://
milconnect.dmdc.osd.mil to view specific information. For additional information on TRICARE, visit the TRICARE website at
www.tricare.mil or the Regional Contractor's website at: www.tricare-overseas.com
REGIONAL CONTRACTOR: REGION, ADDRESS, TELEPHONE AND FAX NUMBERS:
Region: OVERSEAS REGION
Address: International SOS Government Services, LLC, PO Box 760217, San Antonio, TX 78245
Toll-Free Number: www.tricare-overseas.com/contact-us
Fax Number: 1-215-773-2740
DD FORM 2876-3, FEB 2025
PREVIOUS EDITION IS OBSOLETE.
CUI (when filled in)
Controlled by: DHA
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CUI Category: PRVCY, HLTH
LDC: FEDCON
POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil
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(Updated YYYYMMDD)
SPONSOR'S SSN/DBN:
TRICARE PRIME OPTION DESIRED:
TRICARE Prime: Overseas Family members must be command sponsored and meet specific enrollment criteria of the overseas
area. Retirees are not eligible for TRICARE Prime Overseas.
TRICARE Prime Remote Overseas: If eligible, you may be enrolled in TRICARE Prime Remote Overseas. Family members must
be command sponsored and meet specific enrollment criteria of the overseas area.
SECTION I - SPONSOR INFORMATION
2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN)
(XXX-XX-XXXX) or DoD BENEFITS NUMBER (DBN)
1. SPONSOR'S NAME (Last, First, Middle Initial) (Must match DEERS)
(XXXXXXXXX-XX)
3. SPONSOR IS: (X one)
Active Duty
Retired
4. SPONSOR'S TELEPHONE NUMBER (Include Area Code)
Deceased (Go to Section II.)
Unremarried Former Spouse
5. SPONSOR'S E -MAIL ADDRESS
6. SPONSOR'S
DATE OF BIRTH
c. CELL:
a. WORK:
(YYYYMMDD)
b. HOME:
7. SPONSOR'S RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code, Country)
8. SPONSOR'S MAILING ADDRESS (Provide APO or FPO if stationed overseas)
New
Same as residence
New
9. SPONSOR'S MILITARY ASSIGNMENT
a. UNIT
c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS
b. UNIT IDENTIFICATION CODE (UIC) (If known)
10. SPONSOR'S REQUESTED ACTION (X one)
Enroll
None (Go to Section II.)
Transfer Enrollment
PCM Change
Disenroll (Non-AD only)
Effective Date Requested (YYYYMMDD):
11. SPONSOR'S PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability
and your uniformed service guidelines. Review PCM options online or call your Regional Contractor or preferred MTF (non-active
duty only) for availability of PCMs.)
a. 1st CHOICE MTF
FULL NAME or MTF/CLINIC
MTF
PRP
(ADSM)
b. 2nd CHOICE
MTF
FULL NAME or MTF/CLINIC
c. PCM SPECIALTY
No Preference
d. PREFERRED PCM SEX
DD FORM 2876-3, FEB 2025
PREVIOUS EDITION IS OBSOLETE.
Family/General Practice
No Preference
Male
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Internal Medicine
Flight Medicine
Female
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SPONSOR'S SSN/DBN:
SECTION II - ENROLLING FAMILY MEMBER INFORMATION OR PCM CHANGE (Use additional copies of this page as necessary)
12.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. REQUESTED ACTION :
Enroll
Transfer Enrollment
b. DATE OF BIRTH (YYYYMMDD)
PCM Change
Disenroll
Effective Date Requested (YYYYMMDD):
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
Same as Sponsor
New
e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
a. WORK:
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor customer services for availability of PCMs.)
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
i. PREFERRED PCM SEX
No Preference
FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC
Family/General Practice
No Preference
Internal Medicine
Male
Enroll
Transfer Enrollment
Flight Medicine
Female
13.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. REQUESTED ACTION :
Pediatrics
b. DATE OF BIRTH (YYYYMMDD)
PCM Change
Disenroll
Effective Date Requested (YYYYMMDD):
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
Same as Sponsor
New
e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
a. WORK:
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor customer services for availability of PCMs.)
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
i. PREFERRED PCM SEX
No Preference
FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC
Family/General Practice
No Preference
Internal Medicine
Male
14.a. FAMILY MEMBER NAME (Last, First, Middle Initial) (Must match DEERS)
c. REQUESTED ACTION :
Enroll
Transfer Enrollment
Pediatrics
Flight Medicine
Female
b. DATE OF BIRTH (YYYYMMDD)
PCM Change
Disenroll
Effective Date Requested (YYYYMMDD):
d. RESIDENCE AND MAILING ADDRESS (Provide address, with ZIP Code and Country, if different from Sponsor)
Same as Sponsor
New
e. TELEPHONE NUMBER (Include Area Code)
f. E -MAIL ADDRESS
a. WORK:
b. HOME:
c. CELL:
g. PCM PREFERENCE (Please list your first and second choices below. PCM assignment depends upon availability and uniformed service guidelines.
Review PCM options online or call your Regional Contractor customer services for availability of PCMs.)
(1) 1st CHOICE
MTF
Civilian
Same as Sponsor
(2) 2nd CHOICE
MTF
Civilian
Same as Sponsor
h. PCM SPECIALTY
i. PREFERRED PCM SEX
No Preference
DD FORM 2876-3, FEB 2025
PREVIOUS EDITION IS OBSOLETE.
FULL NAME or MTF/CLINIC
FULL NAME or MTF/CLINIC
Family/General Practice
No Preference
Male
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Internal Medicine
Pediatrics
Flight Medicine
Female
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SPONSOR'S SSN/DBN:
SECTION III - REASON FOR DISENROLLMENT OR PCM CHANGE
(Complete if disenrolling or making a PCM change)
Name of Family Member:
Name of Family Member:
Name of Family Member:
Name of Family Member:
Relocation
Dissatisfied
PCS
Other:
Relocation
Dissatisfied
PCS
Other:
Relocation
Dissatisfied
PCS
Other:
Relocation
Dissatisfied
PCS
Other:
SECTION IV - OTHER HEALTH INSURANCE
PLEASE IDENTIFY IF ANYONE IS CURRENTLY COVERED BY OTHER HEALTH INSURANCE.
TRICARE Supplement (no other information is needed)
Medical Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Dental Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Vision Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
Prescription Insurance:
Person(s) Covered:
Policy Holder Name:
Carrier Name:
Policy Number:
Policy Effective Date:
SECTION V - SIGNATURE (REQUIRED)
I understand if I selected a PCM by name, team, or location (MTF or civilian), TRICARE will enroll me with that PCM subject to PCM
availability and uniformed services policy. I understand that it is my responsibility to comply with all TRICARE Prime Overseas, and/or
TRICARE Prime Remote Overseas policies and procedures. By signing this form, I certify the information provided is true, accurate and
complete. Federal funds are involved in this program and any false claims, statements, comments, or concealment of a material fact may
be subject to fine and/or imprisonment under applicable Federal law.
1. SIGNATURE OF SPONSOR, SPOUSE, OR OTHER
LEGAL GUARDIAN OF BENEFICIARY
2. RELATIONSHIP TO SPONSOR
3. DATE SIGNED (YYYYMMDD)
ENROLLMENT NOTE: Your regional contractor will process your enrollment, disenrollment or change request to be effective on the date requested or the
date of event (e.g., initial eligibility, marriage, birth) as appropriate. If your regional contractor receives your enrollment request within 90-days of loss of other
TRICARE or healthcare coverage, your TRICARE Prime coverage can start on the day after the loss of your other coverage. You should confirm the
enrollment or change before obtaining care by calling your Regional Contractor or by viewing your enrollment on
milConnect (www.tricare.mil/milconnect).
DISENROLLMENT NOTE: If you voluntarily disenroll, you will only have space available care at a military hospital or
clinic. You may re-enroll during the next open enrollment period or within 90-days of a qualifying life event (see www.tricare.mil/LifeEvents for details).
DD FORM 2876-3, FEB 2025
PREVIOUS EDITION IS OBSOLETE.
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| File Type | application/pdf |
| File Title | DD Form 2876-3, "TRICARE PRIME ENROLLMENT, DISENROLLMENT, AND PRIMARY CARE MANAGER (PCM) CHANGE FORM (OVERSEAS)" |
| Author | DoD Component |
| File Modified | 2025-06-10 |
| File Created | 2022-04-18 |