Information Collection

TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

IC 5604 under ICR 200911-0720-004 · OMB 0720-0028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0028 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD From 2852 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	Form
DD From 2852 TRICARE Plus Enrollment Application dd2853.pdf	Form
DD Form 2854 TRICARE Plus Disenrollment Form dd2854.pdf	Form

IC Title:

TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD From 2852	TRICARE Plus Enrollment Application	dd2853.pdf		Yes	No	Fillable Printable
Form	DD Form 2854	TRICARE Plus Disenrollment Form	dd2854.pdf		Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25,065

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	25,065	10,776	14,289
Annual IC Time Burden (Hours)	2,933	1,397	1,536
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.