Information Collection

Reserve Component Health Coverage Request

IC 267518 under ICR 202405-0720-003 · OMB 0720-0081.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 2896-1 Reserve Component Health Coverage Request	Form
TRSTRR BWE Screenshots.pdf	Other-Beneficiary Web Enrollment
TRSTRR BWE Screenshots.pdf	Other-Beneficiary Web Enrollment
DD Form 2896-1 RESERVE COMPONENT HEALTH COVERAGE REQUEST 0720-RCHC_dd2896-1.pdf www.tricare.mil/bwe	Form
DD Form 2896-1 RESERVE COMPONENT HEALTH COVERAGE REQUEST 0720-RCHC_dd2896-1.pdf www.tricare.mil/bwe	Form

IC Title:

Agency IC Tracking Number:

0720-RCHC

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD Form 2896-1	RESERVE COMPONENT HEALTH COVERAGE REQUEST	0720-RCHC_dd2896-1.pdf	https://www.tricare.mil/bwe	Yes	Yes	Fillable Fileable
Other-Beneficiary Web Enrollment			TRSTRR BWE Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Defense Manpower Data Center (DMDC) 02 DoD, Defense Enrollment Eligibility Reporting Systems (DEERS)

FR Citation: 87 FR 32384

Number of Respondents: 98,887

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	197,774	197,774
Annual IC Time Burden (Hours)	49,444	49,444
Annual IC Cost Burden (Dollars)	358,465	358,465

Documents for IC

table that charts IC Documents
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.