TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

Forms and Documents

Document	Type	Status	Availability
Form DD From 2852 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	Form	Modified	Repair queued
SSN Justification.pdf	Supplementary Document	Uploaded 2013-09-30	Available
Supp Statement FINAL.doc	Supporting Statement A	Uploaded 2013-09-30	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
5604	TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	Form	Modified

ICR Details

OMB Control No: 0720-0028	ICR Reference No: 201309-0720-001
Status: Historical Active	Previous ICR Reference No: 200911-0720-004
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/2014
	Date Received in OIRA: 10/22/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	25,065	0	0
Time Burden (Hours)	2,924	0	0
Cost Burden (Dollars)	75,446	0	0

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Abstract: The collection instrument is used to collect information from eligible beneficiaries who want to enroll in or disenroll from TRICARE Plus. TRICARE Plus is an enrollment option for TRICARE beneficiaries who want an affiliation with a primary care provider at a Military Treatment Facility (MTF) and are either ineligible for TRICARE Prime or prefer a more limited relationship (primary care only). The collection instrument is used by contractors to determine beneficiary eligibility and to identify the selection of a health option.

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Authorizing Statute(s): US Code: 10 USC 1099 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 71176	11/29/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 59341	09/26/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	DD Form 2854, DD From 2852	TRICARE Plus Enrollment Application ,   TRICARE Plus Disenrollment Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,065	0	0	0	0	25,065
Annual Time Burden (Hours)	2,924	0	0	0	-9	2,933
Annual Cost Burden (Dollars)	75,446	0	0	0	75,446	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Adjustment is due to reinstatement of a currently approved collection. Burden hours adjustments are due to the ever changing access to TRICARE Plus. The only changes to the forms were the Privacy Act Statement and the Agency Disclosure Notice.

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Annual Cost to Federal Government: $216,561

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/22/2013

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