TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request

TRICARE Plus Enrollment and Disenrollment Application Forms

OMB: 0720-0028

IC ID: 5604

Information Collection (IC) Details

View Information Collection (IC)

TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
 
No Modified
 
Required to Obtain or Retain Benefits
 
32 CFR 199

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DD Form 2853 TRICARE Plus Enrollment Application dd2853.pdf Yes No Fillable Printable
Form DD Form 2854 TRICARE Plus Disenrollment Request dd2854.pdf Yes No Fillable Printable

Defense and National Security Operational Defense

Military Health Information System   78 FR 69076

6,134 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 6,134 0 2,829 0 0 3,305
Annual IC Time Burden (Hours) 716 0 330 0 0 386
Annual IC Cost Burden (Dollars) 5,153 0 2,377 0 0 2,776

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