Download the form
DD Form 2569 is a Department of Defense form, not a service form: DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft, used to Third Party Collection Program/Medical Services Account/Other Health Insurance. The DD prefix is the operative fact. It means one blank serves every military department — Army, Navy, Air Force, Marine Corps, Space Force, Coast Guard under Defense jurisdiction — plus the defense agencies and combatant commands. No branch variant exists.
not stated is the prescribing publication and not stated the office responsible for the document. Deadlines belong to local implementing guidance, not to either of those, so a submission date is a question for the receiving office.
Current edition is not stated, carried as not stated. Check that against any copy you already hold before doing anything else — Department-level revisions land everywhere simultaneously, so a stale file is stale across the whole Department.
Available: PDF, across 2 pages, roughly 94 fields. That is the whole scope of the download decision.
Default to fillable pdf, print only when you must. The fillable file stores what you type; the printable file is a blank picture. A Department form often travels further than a service form — scanned, emailed, forwarded to an agency that never saw the original — and typed text is what survives that.
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.
Verify the edition before the first keystroke. The date on the form face should read not stated. If it does not, discard the file. Field numbering shifts between editions, and on a DD form the new layout reaches every receiving office in every service at once — there is no lag during which the old version is still normal somewhere.
Unclear entries — read the form face, then not stated; the directive prevails.
Send it as not stated or local guidance specifies. Save a copy. Cross-service and cross-agency routing is normal for Department forms, and a lost original outside your own organization is harder to chase down.
Related forms are found by number alone. The DD sequence is one unified Department-wide series, so a cited number resolves to exactly one document with no branch qualifier needed.
Do not read across from a service number. DA numbering is Army-specific under an Army proponent; DD numbering is Department-wide under not stated or an equivalent Department office. The sequences are unrelated, so identical digits in each identify two different documents. Read the prefix, not the digits.
Revision follows directive changes, changed data requirements and amended notice language, unannounced. Verify not stated each time rather than trusting a saved copy — the cost of the check is seconds.
Limits of this page: it distributes a published Department of Defense document and describes it. No legal advice, no procedural ruling, no statement about whether any submission will be accepted. Applicability, eligibility and procedure belong to not stated, to a servicing personnel office, or to the office named 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?