Dd Form 2569 - Third Party Collection Program/medical Services Account/ Other Health Insurance Patient Information
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2THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES ACCOUNT/
OMB No. 0704-0323
OTHER HEALTH INSURANCE
OMB approval expires
Mar 31, 2013
(Read Privacy Act Statement before completing this form.)
The public reporting burden for this collection of information is estimated to average 3 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, Information Management Division, 4800 Mark
Center Drive, Alexandria, VA 22350-3100 (0704-0323). 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 1095 and 1079b; Executive Order 9397.
PRINCIPAL PURPOSE(S): Information will be used to collect from private insurers for medical care provided to the Military Treatment Facility (MTF)
patient. Such monetary benefits accruing to the MTF will be used to enhance health care delivery in the MTF.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act, the information on this form will be
released to your insurance company.
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)
4a. MAILING ADDRESS
b. HOME TELEPHONE NO.
(Include ZIP Code)
(
)
5a. FAMILY MEMBER
b. SPONSOR SSN
PREFIX
6a. PATIENT'S EMPLOYER'S NAME
b. EMPLOYER TELEPHONE NUMBER
(
)
INSURANCE INFORMATION
7. DO YOU HAVE OTHER HEALTH INSURANCE? (This includes employer health insurance benefits, other commercial health insurance
coverage, and Medicare Supplement.)
a. YES. (Complete Item 8 and the remaining sections below.)
b. NO, I am a DoD beneficiary and rely solely on TRICARE, Medicare, or Medicaid. (Proceed to Item 12.)
c. NO, but I am not a DoD beneficiary. (Proceed to Item 11.)
8. 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 10; 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)
(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, FEB 2011
PREVIOUS EDITION IS OBSOLETE.
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