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Department of Defense form 2569. Official designation: DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft. Purpose: Third Party Collection Program/Medical Services Account/Other Health Insurance. Current edition not stated, status not stated.
Prescribing authority: not stated. Proponent: not stated. Unlike service-specific publications, DD forms carry Department-level authority and apply across the Army, Navy, Air Force, Marine Corps, Space Force and Coast Guard when operating under Defense jurisdiction.
Common users: service members regardless of branch, Defense civilian staff, and the offices that file, verify or retain the finished document.
Submission follows the schedule set by not stated and by local implementing procedures. This page provides the blank form for download and general orientation only.
Formats offered: PDF. Length: 2 pages. Fillable field count: roughly 94.
Distribution centres on pdf. Two states exist: fillable, where field boxes accept keyboard input and retain it, and printable, a static blank produced for manual completion. Typed data reproduces cleanly across copies; handwritten data depends on the writer.
What the form asks for
- 3. Date of birth: four digit year, two digit month, two digit day, separated by slashes.
- 1. Patient name (last, first, middle initial).
- 4.a. Mailing address (include zip code).
- 4.b. Home telephone number. Area code only.
- 6. Remainder of home telephone number.
- 2. Social Security Number or other identification number.
- 5.b. Sponsor Social Security Number, do not include dashes.
- 6.b. Employer telephone number: area code only.
- 6.b. Remainder of employer's telephone number.
- 6.a. Name of patient's employer.
- 8. Do you have other health insurance? Press space bar to mark X in first box if Yes, second box if No, am a DoD beneficiary, or third box if No, not a DoD beneficiary.
- 9. Primary medical insurance information. a. Name of policy holder (last, first, middle initial).
- b. Date of birth (4 digit year/ 2 digit month/ 2 digit day).
- c. Relationship to policy 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 (4 digit year/ 2 digit month/ 2 digit day).
- n. (1) Pharmacy (Rx) insurance company name, address and telephone number.
Order of completion: identification block first, substantive entries second, certification and signature last. The blank is laid out in that sequence and the sequence is not arbitrary — later entries often depend on data established in the header.
The current edition is not stated. Superseded editions of DD forms are frequently rejected at the receiving office, since Department-wide forms change centrally and older layouts lose their field correspondence. Edition date appears in the lower corner of the printed blank.
Instructions printed on the form or in not stated govern individual field entries. Where the two differ, the governing publication controls.
Once executed, routing follows not stated and the submitting organization's own instruction. Keeping a copy is standard.
Cross-referenced forms are found through the numbering system. The DD sequence is Department-level and unified, which means a number cited on the page identifies one document across the whole Department.
A DD number and a DA number may appear in the same instruction without being related. DA forms belong to the Army alone; DD forms belong to the Department and are administered at Department level. The sequences are independent.
Revision occurs when the prescribing directive is reissued, when the data collected changes, or when statutory notice language is amended. Verification of the edition date at download addresses all three.
The material here is descriptive. Nothing on the page constitutes legal or procedural advice, and no statement here determines whether a submitted form will be accepted. Such questions go to not stated, a servicing administrative office, or the authority identified in not stated.
Questions and answers
- What is DD Form 2569?
- DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?