TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.