Information Collection

TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

IC 5604 under ICR 202104-0720-002 · OMB 0720-0028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0028 can be found here:

Documents and Forms

Document Name Document Type
Form DD2853 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request Form
DD2853 TRICARE Plus Enrollment Application dd2853 draft 20210114.pdf Form
DD2853 TRICARE Plus Enrollment Application dd2853 draft 20210510.pdf Form
DD2854 TRICARE Plus Disenrollment Request dd2854 draft 20210114.pdf Form
DD2854 TRICARE Plus Disenrollment Request dd2854 draft 20210510.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request	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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD2853	TRICARE Plus Enrollment Application	dd2853 draft 20210510.pdf		Yes	No	Fillable Printable
Form	DD2854	TRICARE Plus Disenrollment Request	dd2854 draft 20210510.pdf		Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: Military Health Information System	FR Citation: 78 FR 69076

Number of Respondents: 3,305	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,305	3,305
Annual IC Time Burden (Hours)	386	386
Annual IC Cost Burden (Dollars)	2,776	2,776

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.