OMB control number
Third Party Collection Program (Insurance Information)
OMB 0720-0055 · DOD/DODOASHA.
OMB 0720-0055
DOD is required to collect from third party payers the cost of medical care provided to retirees, dependents and others utilizing the services of Military Treatment Facilities (MTFs) who have private health insurance. The funds collected will be used to enhance the services provided in the MTF that provided the original care. This form is designed to solicit information from the beneficiaries concerning their health insurance coverage.
The latest form for Third Party Collection Program (Insurance Information) expires 2026-12-31 and is listed under ICR 202305-0720-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form DD Form 2569 Third Party Collection Program (Insurance Information) | Form |
 0720-0055_SSA_10.23.23.docx | Supporting Statement A |
| 0720-0055_SSN Justification Memo_06.27.2023.pdf | Supplementary Document |
 Third Party Collection Program (Insurance Information) |
Form |
| e2569 Module |
Other-Screenshots |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202305-0720-001 | Revision of a currently approved collection | 2023-11-01 | Approved without change | |
| 202210-0720-001 | Revision of a currently approved collection | 2022-10-24 | Approved without change | |
| 202205-0720-001 | Revision of a currently approved collection | 2022-09-08 | Improperly submitted and continue | |
| 201908-0720-002 | Revision of a currently approved collection | 2019-08-29 | Approved without change | |
| 201606-0720-003 | Revision of a currently approved collection | 2016-06-30 | Approved without change | |
| 201304-0720-003 | Revision of a currently approved collection | 2013-04-30 | Approved without change | |
| 201304-0720-001 | Extension without change of a currently approved collection | 2013-04-11 | Approved without change |
OMB Details
Third Party Collection Program (Insurance Information)
Federal Enterprise Architecture: Defense and National Security - Operational Defense
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form DD Form 2569 | Third Party Collection Program/Medical Services Account/Other Health Insurance | Fillable Fileable Signable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.