TRICARE Select Enrollment, Disenrollment, and Change Form

TRICARE Select Enrollment, Disenrollment, and Change Form

OMB: 0720-0061

IC ID: 229387

Information Collection (IC) Details

View Information Collection (IC)

TRICARE Select Enrollment, Disenrollment, and Change Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction DD-3043 TRICARE Select Enrollment, Disenrollment, and Change Form DD3043-1-East.pdf Yes No Fillable Printable
Form and Instruction DD-3043 TRICARE Select Enrollment, Disenrollment, and Change Form DD3043-2-West.pdf Yes No Fillable Printable
Form and Instruction DD-3043 TRICARE Select Enrollment, Disenrollment, and Change Form DD3043-3-Overseas.pdf Yes No Fillable Printable
Other-Screenshot BWEPortal.jpg https://www.tricare-west.com/content/hnfs/home/tw/bene/enroll/tools/bwe.html Yes Yes Fillable Fileable
Other-Screenshot Military.com BWE Article Screen Shot.docx No   Fillable Fileable
Form and Instruction DD-3043 TRICARE Select Enrollment, Disenrollment, and Change Form DD3043 Final 20171206.PDF Yes No Fillable Printable

Defense and National Security Operational Defense

EDHA07 - Military Health Information System  78 FR 69076

99,300 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 99,300 0 0 0 0 99,300
Annual IC Time Burden (Hours) 24,825 0 0 0 0 24,825
Annual IC Cost Burden (Dollars) 179,733 0 0 0 0 179,733

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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