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This version of the form is not currently in use and is provided for reference only. Download this version of
DD Form 2569
for the current year.
DD Form 2569 Third Party Collection Program / Medical Services Account / Other Health Insurance
What Is DD Form 2569?
This is a form that was released by the U.S. Department of Defense (DoD) on March 1, 2020. The form, often mistakenly referred to as the DA Form 2569 Attorney of Record Designation for Civilian Counsel, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DoD.
FAQ
Q: What is DD Form 2569?
A: DD Form 2569 is a form used for the Third Party Collection Program.
Q: What is the Third Party Collection Program?
A: The Third Party Collection Program is a program that allows the Department of Defense to collect payment for medical services provided to individuals who have other health insurance.
Q: What is a Medical Services Account?
A: A Medical Services Account is an account that is created to track and manage the collection of payments for medical services provided by the Department of Defense.
Q: What is Other Health Insurance?
A: Other Health Insurance refers to any health insurance coverage that an individual has, other than the insurance provided by the Department of Defense.
Form Details:
- A 2-page document available for download in PDF;
- The latest version available from the Executive Services Directorate;
- Editable, printable, and free to use;
- Fill out the form in our online filing application.
Download an up-to-date fillable DD Form 2569 down below in PDF format or browse hundreds of other DoD Forms compiled in our online library.
Download DD Form 2569 Third Party Collection Program / Medical Services Account / Other Health Insurance
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