Dd Form 2569 - Third Party Collection Program/medical Services Account/other Health Insurance Page 2

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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)

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)

18. VERIFICATION