Which document is this? DD Form 2569, official title DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft. What does it do? It exists to Third Party Collection Program/Medical Services Account/Other Health Insurance. Everything on this page builds on those two facts.
Does it apply to your branch? Yes. The DD prefix means Department of Defense, not one service, so the same blank serves the Army, Navy, Air Force, Marine Corps, Space Force and the Coast Guard under Defense jurisdiction. There is no Army version and no Navy version to search for.
Who decides this form exists? not stated owns it; not stated directs its use. If someone told you to file this, the authority traces back to those.
Is this the right edition? The current one is dated not stated, and the publisher carries it as not stated. Check that against whatever copy you already have before going further.
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.
Download the form
Which files are here? These: PDF. How much work is involved? 2 pages, about 94 entry fields.
Do you pay for these? No. Free download, every format. What should you avoid? Filling the form inside a browser tab; the fields frequently do not save.
Can you skip around the form? Better not to. The layout runs identification, then content, then certification, and entries near the bottom frequently take their meaning from what sits above them.
What if your copy is old? Replace it. Check the date printed on the form against not stated. Old blanks circulate for years in shared folders, and because a DD revision lands across the whole Department at once, the receiving office will be working from the new layout.
Can you leave fields blank? Not safely. A reviewer cannot tell a deliberate omission from a missed question, so mark inapplicable items N/A. And date fields? Match the format shown on the form — conventions differ, and misreading a date is easy.
What does the Privacy Act notice cover? Four things: the legal authority behind the collection, the purpose, the routine uses, and whether disclosure is required. When should you read it? Before entering personal information, while the choice is still open.
How do you sign electronically? With a digital signature, usually CAC-based, in a reader that handles it. Will typing your name work? Not as execution — it fills a field without certifying anything. Either way, the date goes in immediately after.
Which mistakes are worth a final check? Superseded edition, gaps in mandatory fields, unreadable writing on a scanned copy, non-conforming date format, unsigned or undated certification.
Is the form its own instruction manual? Partly. The rest sits in not stated, which is also the authority where the two texts conflict.
What happens after you finish? It routes to the office specified in not stated or in local guidance. And your own record? Save a duplicate first; nobody regrets having one.
How do you find a form referenced inside this one? By its number alone. The DD sequence runs across the entire Department, so a number identifies exactly one document regardless of which service cited it.
Why do some instructions cite both a DA and a DD form? Because the procedure touches both systems, not because the forms are related. Service forms answer to a service proponent; DD forms answer to not stated or another Department office. The sequences were never aligned.
How often does a form like this change? Unpredictably — revision follows directive changes, altered collection requirements and updated notice language. What is the practical defence? Verifying not stated every time you download rather than trusting a saved copy.
What does this page actually provide? The blank form and a description of it. What does it not provide? Legal guidance, procedural rulings, or any assurance about a particular filing. Who answers those? not stated, the administrative office that serves you, 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?