TRICARE Retiree Dental Program Enrollment Appication

TRICARE Retiree Dental Program Enrollment Application

Documents and Forms

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

Information Collection (IC) Details

IC Title:	TRICARE Retiree Dental Program Enrollment Appication	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:

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 %

	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

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.