Get Dd 2569, Third Party Collection Program/medical Services Account ... - Crdamc Amedd Army

Filling out the DD 2569 form is essential for individuals seeking to facilitate the collection of medical expenses from third-party insurers. This guide offers clear, step-by-step instructions on how to complete this form accurately to ensure proper processing of your medical services account.

Follow the steps to successfully complete the DD 2569 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient information section. Enter the patient’s full name in the format of last name, first name, and middle initial. Provide the social security number and date of birth in the specified YYYY/MM/DD format. Include a home telephone number and mailing address, ensuring the ZIP code is also included.
3. If the patient is a family member, indicate their prefix, and enter the sponsor's social security number and employer's telephone number. Complete the employer's name as well.
4. In the insurance information section, state whether the patient has other health insurance. If 'Yes,' complete the primary medical insurance information by providing details such as the policy holder's name, date of birth, relationship to the policy holder, employer information, insurance company details, and policy identifiers.
5. If there is a secondary medical insurance, provide similar information as outlined in step 4, ensuring accuracy in all fields regarding the secondary insurer.
6. For any additional family members covered under the primary policy, complete the details for each member as requested, including their name, social security number, date of birth, and relationship to the policy holder.
7. Complete the Medicare or Medicaid information section if applicable. Fill out the necessary Medicare numbers and any related plan information.
8. In the certification, release, and assignment section, ensure to read the statements carefully before signing. The patient or adult family member must sign and date the form confirming the accuracy of the information provided.
9. If applicable, have a military treatment facility representative sign the form if the patient refuses to sign.
10. Lastly, verify the patient insurance annually. If any information has changed, complete a new form. Confirm verification with initials and date.
11. After thoroughly completing the form, you can save your changes, download, print, or share the form as needed to submit it to the requesting military treatment facility.

Complete your DD 2569 form online today to streamline your medical services account management.