Information Collection

TRICARE Retiree Dental Program Enrollment Appication

IC 5586 under ICR 201604-0720-004 · OMB 0720-0015.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Appication	Form
Delta Dental Form TRICARE Retiree Dental Program Enrollment Application TRDP_enrollment_application_rev__PAS_11.4.2015(2).PDF	Form

IC Title:

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 199.22

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	Delta Dental Form	TRICARE Retiree Dental Program Enrollment Application	TRDP_enrollment_application_rev__PAS_11.4.2015(2).PDF		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: EDHA 07, Military Health Information System

FR Citation: 78 FR 69076

Number of Respondents: 60,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 76 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	60,000	-4,000	64,000
Annual IC Time Burden (Hours)	15,000	-1,000	16,000
Annual IC Cost Burden (Dollars)	375,000	375,000	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.