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⚠️ Notice: This information collection may be referencing outdated material.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 Form 2569 Third Party Collection Program (Insurance Information) Form
DD Form 2569 Third Party Collection Program/Medical Services Account/ DD2569 draft_2022.pdf Form
DD Form 2569 Third Party Collection Program/Medical Services Account/ DD2569 draft_2022.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 Form 2569	Third Party Collection Program/Medical Services Account/Other Health Insurance	DD2569 draft_2022.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: DHA 12 Third Pary Collection System	FR Citation: 78 FR 69076

Number of Respondents: 2,319,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,478,500	-2,431,500	5,910,000
Annual IC Time Burden (Hours)	231,900	-162,100	394,000
Annual IC Cost Burden (Dollars)	7,323,402	-3,610,098	10,933,500

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.