TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD2853 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	Form	Modified	Repair queued
0720-0028_SSA_4.27.2021.DOCX	Supporting Statement A	Uploaded 2021-04-27	Repair queued
SSN Justifciation for DD Form 2853_2854 TRICARE Plus (Dis)Enrollment.pdf	Supplementary Document	Uploaded 2018-02-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5604	TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	Form	Modified

ICR Details

OMB Control No: 0720-0028	ICR Reference No: 202104-0720-002
Status: Received in OIRA	Previous ICR Reference No: 201801-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/27/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2021
Responses	3,305	3,305
Time Burden (Hours)	386	386
Cost Burden (Dollars)	2,776	2,776

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Abstract: The information collection requirement is necessary for enrollment and disenrollment in the Department of Defense's TRICARE Plus Health Plan established in accordance with Title 10 U.S.C. 1099 (which calls for a healthcare enrollment system) and 1086 (which authorizes TRICARE eligibility of Medicare Eligible Persons and has resulted in the development of a new enrollment option called TRICARE Plus) and the Assistant Secretary of Defense for Health Affairs Policy Memorandum to Establish the TRICARE Plus Program, June 22, 2001. The information collected hereby provides the TRICARE contractors with necessary data to determine beneficiary eligibility and to identify the selection of a health care option.

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Authorizing Statute(s): US Code: 10 USC 1099
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 11952	03/01/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 20672	04/21/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	DD2853, DD2854	TRICARE Plus Enrollment Application ,   TRICARE Plus Disenrollment Request

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,305	3,305	0	0	0	0
Annual Time Burden (Hours)	386	386	0	0	0	0
Annual Cost Burden (Dollars)	2,776	2,776	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $28,545

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/27/2021

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