PURPOSE: DD Form 2569 collects individual's information to assist the Department of Defense (“DoD”) in its recovery from third parties for medical care provided to an individual in a Military …

RETURN COMPLETED FORM TO REQUESTING MILITARY TREATMENT FACILITY. 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.

What is the DD Form 2569, and why do I need to complete it? The DD Form 2569 is the way you tell DOD about your OHI. The information provided on the DD Form 2569 is used to properly route a health care claim to your OHI provider. Who has to complete this form? All DOD beneficiaries, except active duty, are required to complete the DD Form 2569.

PURPOSE: DD Form 2569 collects individual's information to assist the Department of Defense (“DoD”) in its recovery from third parties for medical care provided to an individual in a Military Treatment Facility.

2025年3月7日 · Service Member Pre-Separation/Transition Counseling and Career Readiness Standards Eform for Service Members Separating, Retiring, Released from Active Duty (REFRAD) (This form is controlled. Contact P&R to obtain a copy)

All DOD beneficiaries, except active duty, are required to complete the DD Form 2569. This includes active duty family members, retirees, and family members of retirees. Q4 How often do I have to complete the DD Form 2569? At every visit, you are required to inform DOD about any OHI you have or any changes since your last appointment.

Each Family member (other than the Active Duty sponsor) needs to have a DD 2569 Other Health Insurance Form completed annually, or when there are changes to your Other Health Insurance information. When turned in, you will receive a Yellow Card as verification of meeting the annual requirement for DD 2569.

Title: DD Form 2569, Third Party Collection Program - Record of Other Health Insurance, January 2004 Created Date: 3/4/2004 1:29:17 PM

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.

RETURN COMPLETED FORM TO REQUESTING MILITARY TREATMENT FACILITY. collection from thirdparty payers; 42 USC. Chapter 32, Third Party Liability For Hospital and Medical Care; EO 9397 (SSN) as amended. Defense.