Information Collection

Third Party Collection Program (Insurance Information)

IC 5378 under ICR 200612-0704-002 · OMB 0704-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0323 can be found here:

Documents and Forms

Document Name Document Type
Form DD-2569 Third Party Collection Program (Insurance Information) Form
DD-2569 Third Party Collection Program/Medical Services Account/ dd2569.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Third Party Collection Program (Insurance Information)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 220

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD-2569	Third Party Collection Program/Medical Services Account/Other Health Insurance	dd2569.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,807,212	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,807,212	2,295,980	511,232
Annual IC Time Burden (Hours)	140,361	119,400	20,961
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.