OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

TRICARE Plus Enrollment and Disenrollment Application Forms

OMB 0720-0028 · DOD/DODOASHA.

OMB 0720-0028

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.

The latest form for TRICARE Plus Enrollment and Disenrollment Application Forms expires 2027-08-31 and is listed under ICR 202406-0720-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form DD Form 2853 TRICARE Plus Enrollment Application TRICARE Plus Disenrollment RequestForm
0720-0028_SSA_6.26.2024.docxSupporting Statement A
SSN Justifciation for DD Form 2853_2854 TRICARE Plus (Dis)Enrollment.pdf Supplementary Document
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202406-0720-001 Revision of a currently approved collection 2024-06-27 Approved without change
202104-0720-002 Extension without change of a currently approved collection 2021-04-27 Approved with change
201801-0720-001 Reinstatement with change of a previously approved collection 2018-02-02 Approved without change
201309-0720-001 Reinstatement with change of a previously approved collection 2013-10-22 Approved without change
200911-0720-004 Reinstatement without change of a previously approved collection 2009-11-16 Approved without change
200506-0720-002 Extension without change of a currently approved collection 2005-06-29 Approved without change
200201-0720-001 New collection (Request for a new OMB Control Number) 2002-01-16 Approved without change