Third Party Collection Program (Insurance Information)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0055 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/ dd2569Feb2011version.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	dd2569Feb2011version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: DHA 12 Third Pary Collection System	FR Citation: 75 FR 79345

Number of Respondents: 2,936,905	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,936,905	-570,485	3,507,390
Annual IC Time Burden (Hours)	146,845	-28,525	175,370
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.