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⚠️ Notice: This information collection may be referencing outdated material.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_WHSrevisedADN_9.16.13.pdf Form
DD Form 2854 TRICARE Plus Disenrollment Form dd2854_WHSrevisedADN_9.16.13.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: 32 CFR 199

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_WHSrevisedADN_9.16.13.pdf		No		Fillable Printable
Form	DD Form 2854	TRICARE Plus Disenrollment Form	dd2854_WHSrevisedADN_9.16.13.pdf		No		Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: Military Health Information System	FR Citation: 71 FR 16127

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	0	25,065
Annual IC Time Burden (Hours)	2,924	-9	2,933
Annual IC Cost Burden (Dollars)	75,446	75,446	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.