Supporting statement for TRDP Form

SUPPORTING STATEMENT FOR PAPERWORK

REDUCTION ACT SUBMISSION — 0720-0015

TRICARE Retiree Dental Program Enrollment Application

1. Need and Use. This form is used by retired and family members of retired Service Members applying for dental coverage under the TRICARE Retiree Dental Program (TRDP). There is also an online application, but due to the age of the population covered under the TRDP, and resistance to electronic formats, there also needs to be a written application form. Authority is found in 10 U.S.C. 1076c.

2. Purpose and Users of the Information. The collection of this information is required to verify the eligibility of those interested in voluntary enrollment into the TRDP. The TRDP is offered by the Department of Defense through the TRICARE Management Activity. The TRDP offers a voluntary group benefits program of comprehensive, cost-effective dental coverage for retired members of the Uniformed Services and their family members, unremarried surviving spouses and children of deceased members, and other select individuals.

3. Information Collection Techniques. When qualifying retired or family members of retired Service Members desires voluntary enrollment into the TRDP, they fill out this form and mail to Dental Dental of California Federal Government Programs, PO Box 537008, Sacramento, CA 95853-7008. The information is used to verify eligibility in the program and then, if applicable, to enroll the individual or the family into the TRDP

4. Duplication. Due to the age of the enrolled population in the TRDP, a written application must be available.

5. Small Businesses. This information collection does not have a significant economic impact on small businesses or entities.

6. Consequences of Not Collecting the Information. A significant number of military retirees may be unable to access this program and their oral health would suffer.

7. Special Circumstances. None. This collection of information is consistent with the guidelines in 5 CFR 1320.5(d)(2).

8. Notice and Comment. Notice has been made in Federal Register (75 FR 60418). No comments were received.

9. Payment/Gifts. No payment or gift will be provided to the respondents. Individual dentists will decide if they require an additional fee for completing the form, or whether they will factor it into their cost of doing business.

10. Confidentiality. The form is scanned into our system and then shredded after 30-days to keep the enrollee information private.

11. Sensitive Questions. There are no questions of a sensitive nature asked on the attached forms.

12. Burden and Annualized Cost Information:

Estimated Respondents: We receive approximately 18,000 paper applications through the US mail; 24,000 by telephone and 22,000 through web enrollment.

Response Time: 15 minutes

Response frequency: once per year

Burden hours: 16,000

The individual cost to the provider is the part of the cost of doing business.

13. Cost to Respondents. There will be no additional cost burden to respondents.

14. Cost to the Government. There will be a minimal cost to the government as the form is designed to be electronically distributed and printed by the military organizations that use the form.

15. Change. This is a reinstatement with change. The form has an updated Privacy Act Statement, an updated Agency Disclosure Notice, and reference to Discover as a payment method. Note that there appears to be a large reduction in the total number of applications (approx 64,000 currently versus 71,332 in 2007). The value of applications reported in 2007 was a miscalculation.

16. Publication. There is no plan to publish or tabulate the information collected in an independent report. Data will be used for enrollment in the TRDP only.

17. Expiration Date.

Approval not to display the expiration date is not being sought.

18. Exceptions.

No exceptions to the certification statement are requested.

B. Collections of Information Employing Statistical Methods.

This collection of information does not employ statistical methods.