TRICARE Select Enrollment, Disenrollment, and Change Form

The information collection is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to: (1) complete his/her enrollment into the “new” TRICARE Select health plan option as created by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, (2) dis-enroll a beneficiary, or (3) change the beneficiary’s enrollment (e.g., address, add a dependent, report other health insurance. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice.

The latest form for TRICARE Select Enrollment, Disenrollment, and Change Form expires 2027-11-30 and is listed under ICR 202407-0720-001.