DD Form 2569 occupies a particular place in Defense recordkeeping. Its title is DD 2569, Third Party Collection Program/Medical Services Account/Other Health Insurance, 20160525 draft, and it exists to Third Party Collection Program/Medical Services Account/Other Health Insurance. What the DD prefix records is an administrative judgment made long before your copy was printed: this transaction was determined to be common to the whole Department rather than peculiar to one service, and so the documentation of it was standardized at Department level.
The practical effect of Department-level issue is interoperability. not stated establishes the requirement across the Defense enterprise; not stated keeps the document current for all of it. No service maintains its own variant, which means a completed record travels between components — service to agency, agency to joint command — and arrives in a format the receiving office already knows how to read.
You are looking for edition not stated, listed as not stated. Department-wide supersession is a single event rather than a rollout, which is what distinguishes edition currency on a DD form from the same question on a service publication: nobody anywhere is still accepting the previous version out of habit.
The sequence printed on the form is the sequence in which a reviewer will read it, and the two should agree. Header data frames every entry below it; the substantive fields depend on that frame; the certification stands at the end because its whole function is to vouch for what came before. Entries made out of sequence commonly contradict entries made earlier.
Check the edition date before you type anything, against not stated. Old blanks accumulate in shared drives for years, and the cost of one is not obvious until a reviewer cannot find a field. Because DD forms are revised centrally and replaced across the Department in a single action, there is no component still tolerating the old layout as a local practice.
Where a specific field is genuinely unclear, the instructions printed on the form come first and not stated governs where the two do not agree.
Download the form
The set published here is PDF, covering 2 pages with roughly 94 fields. More than one format survives because the Department serves users under very different conditions, from a desk with current software to a location where a printer is the only reliable output.
The difference between a fillable and a printable pdf is a difference in what the file contains. A fillable release carries an interactive layer: each box is a defined field with a name and a data type, and what you type is stored as data inside the document. A printable release has no such layer — it is an image of the page, and the only place your answers can go is onto paper. The distinction matters downstream, because a Department record often gets scanned and forwarded several times before it reaches its final file, and typed characters survive that chain in a way pen strokes do not.
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.
Submission follows not stated and whatever local instruction supplements it. Make a copy before the original leaves. Department forms travel across organizational lines by design, and the administrative distance that makes them useful is the same distance that makes tracing a lost one difficult.
Cross-referenced documents are found by series and number, with nothing further required. That the DD sequence is unified across the Department means a cited number identifies one form and no other, which is the practical payoff of centralizing the numbering in the first place.
It helps to see the DA and DD sequences as what they are: separate registries with separate custodians. One serves a single service under a service proponent, the other serves the Department under not stated or an equivalent office, and neither was ever indexed against the other. A number that appears in both systems points to two unrelated documents, which is why reading the prefix comes before reading the digits.
Editions change for reasons that originate above the form itself. The prescribing directive is reissued and the form follows; the information the Department needs to collect changes and the fields change with it; the statutory notice language is amended and every form carrying that notice is republished. None of these events announces itself to the person who downloaded a copy last year, which is why confirming not stated at the moment of download is the only reliable check available to you.
What you have here is the document and a description of it, which is a different thing from guidance. This page is not an organ of the Department, gives no legal or procedural advice, and makes no representation about the outcome of any filing; the offices that administer the requirement are the only ones positioned to answer that. Applicability, eligibility and procedural questions belong to not stated, to your servicing personnel office, or to the office designated 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?