TRICARE Select Enrollment, Disenrollment, and Change Form

Documents and Forms

Document Name Document Type
BWE TSelect Enrollment Flow.docx www.tricare-west.com/content/hnfs/home/tw/bene/enroll/tools/bwe.html Other-Screenshot
BWE TSelect Enrollment Flow.docx www.tricare-west.com/content/hnfs/home/tw/bene/enroll/tools/bwe.html Other-Screenshot
DD3043-1 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-1.pdf Form and Instruction
DD3043-1 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-1.pdf Form and Instruction
DD3043-2 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-2.pdf Form and Instruction
DD3043-2 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-2.pdf Form and Instruction
DD3043-3 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-3.pdf Form and Instruction
DD3043-3 TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FOR dd3043-3.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE Select Enrollment, Disenrollment, and Change Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screenshot			BWE TSelect Enrollment Flow.docx	https://www.tricare-west.com/content/hnfs/home/tw/bene/enroll/tools/bwe.html	Yes	Yes	Fillable Fileable
Form and Instruction	DD3043-1	TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FORM	dd3043-1.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	DD3043-2	TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FORM	dd3043-2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	DD3043-3	TRICARE SELECT ENROLLMENT, DISENROLLMENT, AND CHANGE FORM	dd3043-3.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: EDHA07 - Military Health Information System	FR Citation: 78 FR 69076

Number of Respondents: 116,105	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 44 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	116,105	16,805	99,300
Annual IC Time Burden (Hours)	29,026	4,201	24,825
Annual IC Cost Burden (Dollars)	210,440	30,707	179,733

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.