Dd Form 2569 - Third Party Collection Program/medical Services Account/other Health Insurance

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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:
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

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