Start here if you have been told to submit DD Form 2569. First, know what you are filling: Third Party Collection Program/Medical Services Account/Other Health Insurance. The document is titled DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft.
Your second step is the edition, not stated, listed as not stated. Your third is scope. Because the number carries a DD prefix, you use the same blank as every other military department and defense agency; no service-specific version exists for you to hunt down.
Then settle the schedule. You are working under not stated, with not stated responsible for the document, and your organization layers its own deadlines on that. Ask before you assume a date.
Before you download, pick your approach — editable file or printed page. What follows covers the formats first, then the entries, then what you do afterward.
Now fill it in. Work from the top of the page downward, and do not jump ahead — the identifying block comes first, the substance of your entry second, the certification last. Later boxes often depend on what you put at the top.
Before your first entry, look at the corner of the page and compare the printed date with not stated. If they do not match, stop and download again. Old copies circulate in shared drives for years, and a DD form is revised centrally for every service at once, so a superseded blank may not carry the fields your reviewer expects.
Take the fields in order and answer all of them. Mark inapplicable items N/A instead of leaving white space. When you reach a date, copy the format shown on the form, since a reviewer reading a different convention may misread your entry entirely.
When you reach a Privacy Act Statement, read it before you continue. It tells you the legal authority for collecting your information, what the Department does with it, who else may see it, and whether you have to answer at all. That last point is worth knowing before you supply personal identifiers, not after.
Finish with the certification. Print the form and sign in ink, or apply a digital signature with your CAC if the receiving office accepts one. Do not type your name in the signature box and consider it done; that is a name, not a signature. Date the block immediately after signing.
Then check your work against the usual failures: an obsolete edition, empty required boxes, handwriting nobody can read after scanning, wrong date format, missing signature or date.
Look up an unclear item on the form face before anywhere else, then in not stated. Should the two texts conflict, the directive is the one you follow.
Download the form
Step one is picking the format. You have PDF to choose from, across 2 pages, with approximately 94 fields to complete.
Whichever you pick, you pay nothing — every format here is a free download. One last tip: open your pdf in a desktop reader rather than in a browser tab, because browser viewers sometimes drop the interactive fields you need.
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.
Now that it is complete, send it where not stated or your local procedure says it goes. Before you do, make yourself a copy — scan it or save the file elsewhere. It costs you nothing and saves you the whole exercise if the original goes missing.
If the form points you to another document, you can find it by number alone. DD numbering runs across the whole Department, so you do not need to work out which service issued it — one number, one form, everywhere.
Be careful when a procedure pairs this form with a service form. Read the prefix, not just the digits. Service forms answer to a service proponent, while DD forms answer to not stated or an equivalent Department office, and the two sequences were never aligned. Grabbing the wrong prefix gets you a form that has nothing to do with your task.
Do not archive this file and reuse it in a year. Forms are reissued as directives are revised, as data requirements shift, and as statutory notice text is amended. Your protection is simple: download fresh each time and confirm the edition date.
Before you go, note what is not covered here. You have the blank form and instructions for completing it; you do not have legal guidance, and no statement on this page determines what any office will do with your submission. Direct those questions to not stated, to the personnel office that serves you, or to the office designated 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?