Download DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance
How to Fill out DD Form 2569?
The statement is made up of two pages with no filing guidelines provided on the form. DD Form 2569 instructions are as follows:
- Section I, Patient Information requires the beneficiaries to provide their name, social security number, date of birth, mailing address (with ZIP code) and phone number in Boxes 1 through 4. The form then requires a family member prefix, the sponsors social security number and the name and phone number of the patient's employe in Boxes 5 and 6;
- Section II, Insurance Information contains 12 parts in total:
- Box 7 specifies whether the patient is eligible for VA benefits. A positive answer requires completing all lines in Box 7 or attaching a copy or a scan of the VA health insurance card to the form;
- Box 8 is for specifying if the patient has a different health insurance plan;
- Box 9 should be completed with information on the beneficiary's primary health care plan. The required information includes the name of the policyholder, the type of insurance and enrollment plan, the effective dates, a card holder ID number and the policy ID. If the patient has an insurance card that can be scanned or copied, the copy must be attached to the form and Box 9 can be skipped entirely;
- Box 10 requires information about a secondary insurance program;
- If any other family members are covered by the health care plans listed above, their names, social security numbers, dates of birth and relationship to the policyholder must be specified in Box 11;
- Box 12 is for information about Medicare and Medicaid. Box 13 contains the certification, release, and assignment;
- Box 14a and 14b are for the patient's signature and date of filing. If the patient refuses to provide their signature, an MTF representative will sign and date the form in Boxes 15a and 15b;
- Boxes 17a and 17b require the patient to sign and date the form again, certifying their agreement with the conditions listed in Box 16.