Third Party Collection Program (Insurance Information)

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 2022-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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

202305-0720-001 Approved without change	Revision of a currently approved collection	2023-11-01
202210-0720-001 Approved without change	Revision of a currently approved collection	2022-10-24
202205-0720-001 Improperly submitted and continue	Revision of a currently approved collection	2022-09-08
201908-0720-002 Approved without change	Revision of a currently approved collection	2019-08-29
201606-0720-003 Approved without change	Revision of a currently approved collection	2016-06-30
201304-0720-003 Approved without change	Revision of a currently approved collection	2013-04-30
201304-0720-001 Approved without change	Extension without change of a currently approved collection	2013-04-11