Information Collection

TRICARE Retiree Dental Program Enrollment Appication

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

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

View Information Collection (IC)

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.