DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance

What Is DD Form 2569?

DD Form 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance is a form used by Department of Defense (DoD) beneficiaries for providing information about health insurances other than TRICARE, Medicare or Medicaid. The TPCP - or the Third Party Collection Program - is an Army program that was introduced in order to facilitate that process.

An up-to-date DD Form 2569 fillable version is available for digital filing and download down below.

DoD beneficiaries include all retirees, family members of retirees and family members of active duty personnel. The DD Form 2569 should be updated annually or after any changes to the beneficiaries personal information or insurance coverage and must be kept in

The newest version of the form - sometimes confused with the DA Form 2569-R, Attorney of Record Designation (Civilian and Individual Military Counsel) - was released by the DoD in September 2016.

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THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES ACCOUNT/
OMB No. 0720-0055
OTHER HEALTH INSURANCE
OMB approval expires
31 Aug, 2019
(Read Privacy Act Statement before completing this form.)
The public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East
Tower, Suite 02G09, Alexandria, VA 22350-3100 (0720-0055). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO REQUESTING MILITARY TREATMENT FACILITY.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 USC, Sections 1079b, Procedures for charging fees for care provided to civilian; retention and use of fees collected;1095, Health care services incurred on behalf of
covered beneficiaries: collection from thirdparty payers; 42 USC. Chapter 32, Third Party Liability For Hospital and Medical Care; EO 9397 (SSN) as amended.
PURPOSE(S): Your information is collected to allow recovery from third parties for medical care provided to you in a Military Treatment FacilityROUTINE USE(S): Your records may be
disclosed outside of DoD to healthcare clearinghouses, commercial insurances providers, and other third parties in order to collect amounts owed to the Department of Defense. Your records may
also be used and disclosed in accordance with 5 USC 552a(b) of the Privacy Act of 1974, a amended, which incorporates the DoD Blanket Routine Uses published at: http://dpcld.defense.gov/Privacy/
SORNsIndex/BlanketRoutineUses.aspx.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD.
Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary. Failure to provide complete and accurate information may result in disqualification for health care services from MTFs.
PATIENT INFORMATION
1. PATIENT NAME
2. SSN
3. DATE OF BIRTH
(Last, First, Middle Initial)
(YYYY/MM/DD)
b. HOME TELEPHONE NO.
(Include ZIP Code)
4a. MAILING ADDRESS
(
)
5a. FAMILY MEMBER PREFIX
b. SPONSOR SSN
b. EMPLOYER TELEPHONE NUMBER
6a. PATIENT'S EMPLOYER'S NAME
INSURANCE INFORMATION
7. ARE YOU ELIGIBLE FOR VETERANS AFFAIRS BENEFITS?
a. YES. (If you have an insurance card (e.g., Veterans Health Identification Card (VHIC), Veterans Choice Card), that can be copied or scanned
by the MTF representative, please provide it and proceed to Item 8; otherwise, please complete items 7.a.(1) through (5) below.)
(2) Plan ID
(1) Member ID
(3) Expiration Date
(YYYY/MM/DD)
(4) VA Facility Name
that assists in coordinating your care
(e.g., primary care/specialty clinic)
(5) VA Facility Address and Telephone Number
(
)
b. NO. (Proceed to Item 8.)
8. DO YOU HAVE OTHER HEALTH INSURANCE? (This includes employer health insurance benefits, other commercial health insurance coverage,
and Medicare Supplement.)
a. YES. (Complete Item 9 and the remaining sections below.)
b. NO, I am a DoD beneficiary and rely solely on TRICARE, Medicare, or Medicaid. (Proceed to Item 13.)
c. NO, but I am not a DoD beneficiary. (Proceed to Item 12.)
9. PRIMARY MEDICAL INSURANCE INFORMATION. If you have an insurance card that can be copied or scanned by the MTF representative,
please provide it and proceed to Item 11; otherwise, please complete the blocks below.
a. NAME OF POLICY HOLDER
b. DATE OF BIRTH
c. RELATIONSHIP TO POLICY
(Last, First, Middle Initial)
(YYYY/MM/DD)
HOLDER
e. INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE
d. POLICY HOLDER'S EMPLOYER'S NAME, ADDRESS AND
NUMBER
TELEPHONE NUMBER
f. CARD HOLDER ID
g. POLICY ID
h. GROUP POLICY ID
i. GROUP PLAN NAME
j. ENROLLMENT/PLAN CODE
k. INSURANCE TYPE
l. POLICY EFFECTIVE DATE
m. POLICY END DATE
(YYYY/MM/DD)
(YYYY/MM/DD)
n.(1) Pharmacy (Rx) Insurance Company Name, Address and Telephone Number
(2) Rx Policy ID
(3) Rx Bin Number
(4) Rx PCN Number
DD FORM 2569, SEP 2016
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional XI
THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES ACCOUNT/
OMB No. 0720-0055
OTHER HEALTH INSURANCE
OMB approval expires
31 Aug, 2019
(Read Privacy Act Statement before completing this form.)
The public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East
Tower, Suite 02G09, Alexandria, VA 22350-3100 (0720-0055). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO REQUESTING MILITARY TREATMENT FACILITY.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 USC, Sections 1079b, Procedures for charging fees for care provided to civilian; retention and use of fees collected;1095, Health care services incurred on behalf of
covered beneficiaries: collection from thirdparty payers; 42 USC. Chapter 32, Third Party Liability For Hospital and Medical Care; EO 9397 (SSN) as amended.
PURPOSE(S): Your information is collected to allow recovery from third parties for medical care provided to you in a Military Treatment FacilityROUTINE USE(S): Your records may be
disclosed outside of DoD to healthcare clearinghouses, commercial insurances providers, and other third parties in order to collect amounts owed to the Department of Defense. Your records may
also be used and disclosed in accordance with 5 USC 552a(b) of the Privacy Act of 1974, a amended, which incorporates the DoD Blanket Routine Uses published at: http://dpcld.defense.gov/Privacy/
SORNsIndex/BlanketRoutineUses.aspx.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD.
Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary. Failure to provide complete and accurate information may result in disqualification for health care services from MTFs.
PATIENT INFORMATION
1. PATIENT NAME
2. SSN
3. DATE OF BIRTH
(Last, First, Middle Initial)
(YYYY/MM/DD)
b. HOME TELEPHONE NO.
(Include ZIP Code)
4a. MAILING ADDRESS
(
)
5a. FAMILY MEMBER PREFIX
b. SPONSOR SSN
b. EMPLOYER TELEPHONE NUMBER
6a. PATIENT'S EMPLOYER'S NAME
INSURANCE INFORMATION
7. ARE YOU ELIGIBLE FOR VETERANS AFFAIRS BENEFITS?
a. YES. (If you have an insurance card (e.g., Veterans Health Identification Card (VHIC), Veterans Choice Card), that can be copied or scanned
by the MTF representative, please provide it and proceed to Item 8; otherwise, please complete items 7.a.(1) through (5) below.)
(2) Plan ID
(1) Member ID
(3) Expiration Date
(YYYY/MM/DD)
(4) VA Facility Name
that assists in coordinating your care
(e.g., primary care/specialty clinic)
(5) VA Facility Address and Telephone Number
(
)
b. NO. (Proceed to Item 8.)
8. DO YOU HAVE OTHER HEALTH INSURANCE? (This includes employer health insurance benefits, other commercial health insurance coverage,
and Medicare Supplement.)
a. YES. (Complete Item 9 and the remaining sections below.)
b. NO, I am a DoD beneficiary and rely solely on TRICARE, Medicare, or Medicaid. (Proceed to Item 13.)
c. NO, but I am not a DoD beneficiary. (Proceed to Item 12.)
9. PRIMARY MEDICAL INSURANCE INFORMATION. If you have an insurance card that can be copied or scanned by the MTF representative,
please provide it and proceed to Item 11; otherwise, please complete the blocks below.
a. NAME OF POLICY HOLDER
b. DATE OF BIRTH
c. RELATIONSHIP TO POLICY
(Last, First, Middle Initial)
(YYYY/MM/DD)
HOLDER
e. INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE
d. POLICY HOLDER'S EMPLOYER'S NAME, ADDRESS AND
NUMBER
TELEPHONE NUMBER
f. CARD HOLDER ID
g. POLICY ID
h. GROUP POLICY ID
i. GROUP PLAN NAME
j. ENROLLMENT/PLAN CODE
k. INSURANCE TYPE
l. POLICY EFFECTIVE DATE
m. POLICY END DATE
(YYYY/MM/DD)
(YYYY/MM/DD)
n.(1) Pharmacy (Rx) Insurance Company Name, Address and Telephone Number
(2) Rx Policy ID
(3) Rx Bin Number
(4) Rx PCN Number
DD FORM 2569, SEP 2016
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional XI
10. SECONDARY MEDICAL INSURANCE INFORMATION. If you have an insurance card that can be copied or scanned by the MTF representative,
please provide it and proceed to Item 11; otherwise, please complete the blocks below.
a. NAME OF POLICY HOLDER
b. DATE OF BIRTH
c. RELATIONSHIP TO POLICY
(Last, First, Middle Initial)
(YYYY/MM/DD)
HOLDER
d. POLICY HOLDER'S EMPLOYER'S NAME, ADDRESS AND TELEPHONE NUMBER
e. INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
f. CARD HOLDER ID
g. POLICY ID
h. GROUP POLICY ID
i. GROUP PLAN NAME
j. ENROLLMENT/PLAN CODE
k. INSURANCE TYPE
l. POLICY EFFECTIVE DATE
m. POLICY END DATE
(YYYY/MM/DD)
(YYYY/MM/DD)
n. (1) Pharmacy (Rx) Insurance Company Name, Address and Telephone Number
(2) Rx Policy ID
(3) Rx Bin Number
(4) Rx PCN Number
11. ARE THERE OTHER FAMILY MEMBERS COVERED UNDER THIS POLICY HOLDER?
a. YES (Complete 11c.-f. and proceed to Item 13.)
b. NO (Proceed to Item 13.)
e. DATE OF
f. RELATIONSHIP
e. DATE OF
f. RELATIONSHIP
c. NAME (Last, First, Middle Initial)
BIRTH
TO POLICY
BIRTH
TO POLICY
d. SSN
c. NAME (Last, First, Middle Initial)
d. SSN
(YYYY/MM/DD)
HOLDER
(YYYY/MM/DD)
HOLDER
12. MEDICARE OR MEDICAID INFORMATION
a. MEDICARE PART A NUMBER b. MEDICARE PART B NUMBER
c. MEDICARE MANAGED CARE PLAN NAME
d. MEDICARE PART D NUMBER AND PLAN NAME
e. MEDICAID NUMBER/MANAGED CARE PLAN NAME/ISSUING
STATE
13. CERTIFICATION, RELEASE, AND ASSIGNMENT
a. I certify that the information on this form is true and accurate to the best of my knowledge. Falsification of information is covered by Title 18,
United States Code, Section 1001, which provides for a maximum fine of $250,000 or imprisonment for five years, or both.
b. I acknowledge that the authority to bill third party payers has been conveyed to the medical facility within the Department of Defense by Title 10,
United States Code, Sections 1095 and 1079b, and that no personal entitlement to reimbursement or payment has been granted to me by virtue
of this act.
c. NON-UNIFORMED SERVICES PATIENTS: I authorize and request that the proceeds of any and all benefits be paid directly to the MTF for
healthcare services provided me and/or my minor dependents. ACKNOWLEDGEMENT: I hereby agree to pay for any service not covered in
whole or in part by my third-party insurer.
d. NON-DoD MEDICARE, MEDICAID AND VETERANS AFFAIRS PATIENTS: I authorize and request that the proceeds of any and all benefits be
paid directly to the MTF for healthcare services provided to me and/or my family member. I acknowledge I am responsible for full payment of any
services not covered by Medicare, Medicaid and Veterans Affairs, including but not limited to patient copayments and deductibles.
e. UNIFORMED SERVICES BENEFICIARIES: I hereby acknowledge that the proceeds of any and all benefits shall be paid directly to the facility of
the Uniformed Service for services provided to me and/or my family member.
f. ALL PATIENTS: I authorize portions of my medical records necessary to support claims for reimbursement for the cost of care rendered to be
released to my insurance carriers.
b. DATE
(YYYY/MM/DD)
14a. PATIENT OR ADULT FAMILY MEMBER SIGNATURE
b. DATE
(YYYY/MM/DD)
15a. IF PATIENT REFUSES TO SIGN THIS FORM: MTF REPRESENTATIVE SIGNATURE
16. ANNUAL PATIENT INSURANCE VERIFICATION
a. If any information on this form has changed, a new form must be completed and signed. Otherwise, after initial signature, verify with your initials
and date at least annually.
b. I certify that the information on this form has been verified on the date(s) specified below, and that all information is true and accurate to the best
of my knowledge.
b. DATE
(Patient or Adult Family Member)
(YYYY/MM/DD)
17a. SIGNATURE
(2) Initials
b.(1) Date
(2) Initials
c.(1) Date
(2) Initials
(YYYY/MM/DD)
(YYYY/MM/DD)
18. VERIFICATION
a. (1) Date
(YYYY/MM/DD)
DD FORM 2569 (BACK), SEP 2016

Download DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance

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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:

  1. 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;
  2. 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.
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