Get Dd Form 2569 Printable Version

Filling out the Dd Form 2569 Printable Version online can simplify the process of providing necessary information regarding health insurance for military treatment facilities. This guide will provide clear steps to assist you in accurately completing the form.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient information. Provide the patient's full name (last, first, middle initial), date of birth, social security number, mailing address (including ZIP code), and home telephone number.
3. Next, provide additional details about the family member, including their prefix and the patient's employer's name and contact number.
4. In the insurance information section, indicate whether the patient has other health insurance. Select 'Yes' to complete the primary medical insurance details or 'No' to proceed based on the patient's status as a DoD beneficiary or non-DoD beneficiary.
5. If the response is 'Yes,' fill out the primary medical insurance details, including the policy holder's name, date of birth, relationship to policy holder, employer information, and the insurance company details.
6. For those with secondary medical insurance, provide similar details as in the primary insurance section.
7. Proceed to specify any additional family members covered under the policy if applicable, or move to the certification section.
8. In the certification section, affirm that the information provided is accurate, and provide the patient or adult family member's signature along with the date.
9. If applicable, complete the signature and date fields for the MTF representative if the patient refuses to sign.
10. Finally, ensure all required information is complete, and save your changes. You can then download, print, or share the completed form as needed.

Start filling out your Dd Form 2569 online today for easier management of your health insurance information.