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 2021-08-31 and can be found here.
Document Name |
---|
Supplementary Document |
Supporting Statement A |
Revision of a currently approved collection | 2024-09-24 | ||
Approved without change |
Extension without change of a currently approved collection | 2021-08-12 | |
Approved without change |
Extension without change of a currently approved collection | 2018-06-21 | |
Approved without change |
New collection (Request for a new OMB Control Number) | 2017-12-08 |