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FORM NUMBER:

DD2569

TITLE:

THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES

ACCOUNT/OTHER HEALTH INSURANCE

EDITION DATE:

20160901

CANCELLATION DATE:

FORMATS:

PLEASE BE ADVISED:

DOWNLOAD FORM

No link under "FORMATS:" indicates no electronic format is available.

To obtain copies of forms, contact YOUR Military Service or Component

Forms Manager click here.

Cancelled forms are not available.

REMARKS:

ISSUANCES:

DoDI 6015.23

SPONSOR / POC:

HA

SUB-SPONSOR:

TMA-OCFO

NUMBER OF PAGES:

2

USERS*:

A N AF

PRESCRIBED OR ADOPTED?:

P

DISPOSITION:

O

SUBJECT GROUP:

6010

FORM CONTROLLED:

N

MANDATORY PRINT SPECIFICATIONS:

N

RCS:

IRCN:

OMB:

0720-0055

PRIVACY ACT IMPLICATIONS:

Y

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* All revisions and/or cancellations must be coordinated through these USERS.

DISPOSITION: O = Do NOT use previous edition. U = Use previous edition until supply is depleted.