Form DD3201 Request for Medical Debt Discount, Military Health Syste

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OMB No. 0720-0083
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REQUEST FOR MEDICAL DEBT DISCOUNT
MILITARY HEALTH SYSTEM MODIFIED PAYMENT AND WAIVER PROGRAM
(Read Privacy Act Statement before completing this form.)

The public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden,
to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. DO NOT RETURN FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO THE ADDRESS STATED ON YOUR MEDICAL BILL.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. Chapter 17, Hospital, Nursing Home, Domiciliary, and Medical Care; 42 U.S. Code § 2651, Federal Medical Care Recovery Act; 32 CFR part 199,
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); and E.O. 9397 (SSN), as amended.
PURPOSE: DD Form 3201 will be used to collect information to assist the Department of Defense (DoD) in determining the eligibility of an individual for the Military Health System Modified Payment and Waiver Program.
ROUTINE USES: These records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to the Departments of Health and Human Services and Veterans Affairs as
per their statutory administrative responsibilities; to Federal, State, local, or foreign governmental agencies and to private business entities related to eligibility, claims pricing and payment, fraud, abuse, reviews, quality
assurance, program integrity, third-party liability, benefits, and litigation related to TRICARE’s operation; to the U.S. Department of Justice and U.S. Attorney’s related to investigations and litigation involving TRICARE; to
third-party contacts if necessary to validate evidence, verify accuracy of information concerning an individual’s entitlement, benefit payment, review of suspected abuse or fraud, or any program integrity or quality
appraisal concern; and the DoD Blanket Routine Uses may apply. For further information regarding routine uses, refer to the applicable SORN hyperlinked below.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not
limited to, treatment, payment, and healthcare operations.
APPLICABLE SORN: EDTMA 04, Medical/Dental Claim History Files (October 27, 2015; 80 FR 65720) https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/
DISCLOSURE: Voluntary. If you choose not to provide the requested information, there may be an administrative delay; however, no penalties will be imposed.

INSTRUCTIONS: To receive consideration for a discount to your medical bill under the Military Health System Modified Payment and Waiver Program, complete this form
in its entirety and provide all requested documentation.

Name (Last, First, Middle Initial):

PATIENT INFORMATION
Date of Birth:
Social Security No.:

Phone Number:

Address Line 1:

Address Line 2:

State:

City:

Zip Code:

If you would like to be notified by e-mail of the status of your application, please provide your e-mail address:
GUARANTOR INFORMATION
(If the patient is a minor under 18 years of age, this is the person responsible for paying the patient’s medical bill)
Date of Birth:
Social Security No.:
Phone Number:
Name (Last, First, Middle Initial):
Address Line 1:

Address Line 2:

City:

State:

Zip Code:

If you would like to be notified by e-mail of the status of your application, please provide your e-mail address:

NEEDS DD67
PLEASE INDICATE WHETHER YOU HAVE PREVIOUSLY APPLIED TO THE PROGRAM

I have previously applied and was approved for a discount. I am reapplying because my financial circumstances have changed.

Yes

No

PLEASE READ AND INITIAL NEXT TO EACH STATEMENT BELOW:

I understand that in order to receive consideration for a discounted medical bill, I must complete and submit the documents listed below within
90 days of the date on my medical invoice and that failure to submit my documents or a payment by that date can result in my account being
turned over to collections.
I understand and agree that if my hospitalization occurred as the result of an action for which another party or person may be responsible, that
the Government may pursue a claim for the reasonable value of the medical care provided. I also agree to cooperate and assist the United
States to recover the cost of care.

Initials:
Initials:

PLEASE RESPOND TO THE FOLLOWING:
1. I am claiming that my hospitalization occurred as the result of an action for which another party or person is responsible. The other

Yes

No

, and in this claim action, I am being

party/person is (if known):

.

represented by (if you have obtained legal representation):

Yes

No

2. Was your injury/illness related to your work? If so, you may be eligible for workers' compensation benefits.

Yes

No

3. Was your injury/illness the result of a crime? If so, you might be eligible for Victims of Crime compensation which could help cover some of
your expenses.

THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH THIS APPLICATION
IMPORTANT: We cannot process incomplete applications. Your application will be returned if required documents are not provided.
1

A copy of the medical bill for which you are seeking a discount.

2

DD Form 2569 – Please note that this form is required even if you do not have health insurance. You may download this form at
https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2569.pdf

3
4

5

Your most recent Federal Income Tax Return – If you did not file Federal Income Tax Returns, please check the box below.
I DID NOT FILE FEDERAL INCOME TAX RETURNS FOR THE PREVIOUS YEAR.
Your last 2 pay stubs. NOTE: If you do not have pay stubs, you may submit other documents that show your income such as Forms 1099-MISC and Forms
1099-R for the previous tax year; your last 2 bank statements; or a letter from your employer stating the amount paid to you monthly or annually.
IF YOU DO NOT RECEIVE ANY INCOME, PLEASE READ AND CERTIFY THE STATEMENT BELOW:
With knowledge of the penalties for false statement provided by 18 U.S.C. § 1001 ($10,000 fine and/or five years imprisonment) and with knowledge that this
financial statement is submitted by me to affect action by the Department of Defense (DoD) or Department of the Treasury acting on behalf of the DoD, I certify
that I do not receive any income from employment, business operations, real estate income (such as from property rental), Social Security payments, pensions,
annuities, insurance policies, unemployment, disability, public assistance, alimony, self-employment, or any other income sources.

Patient/Guarantor Signature
Date
Please provide any additional information or hardship conditions (eviction, job loss, other medical expenses, homelessness, etc.) you would like
considered with your application.

DD FORM 3201, 20260130 DRAFT

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CUI Category: PRVCY
LDC: FEDCON
POC:

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VOLUNTARY REPAYMENT AGREEMENT (VRA)
INSTRUCTIONS: Complete this form if you would like to repay your medical invoice by monthly installment payments.
I,

(debtor), acknowledge that I owe and am obligated to repay a debt to the United

States for healthcare services I received at a Department of Defense (DoD) military medical treatment facility (MTF). I agree to pay the debt under the
following terms and conditions.
1. Payment Obligation
I agree to pay the amount on my initial account statement, or if my account is adjusted due to my eligibility for a discount through the MHS Modified
Payment and Waiver Program, I agree to pay the amount on my adjusted account statement. I acknowledge that failure to submit my payment by the
due date will result in the cancellation of the Voluntary Repayment Agreement and I understand that my account will be transferred to the Department
of the Treasury’s collections center. The Treasury’s collection center may charge interest, late payment penalties, and administrative charges to my
debt.

2. Duration of Payments
NOTE: This is a preliminary election of the duration of your payments. You may change the duration of your payments at any time by calling the phone
number on your invoice. Your debt must be paid off within 72 months (maximum) and monthly payments may not be less than $25 per month.
I elect to repay my debt in

In full

12 months

24 months

36 months

48 months

60 months

72 months

Other (cannot exceed 72 months)

DRAFT

3. Default and Demand for Immediate Payment in Full

In the event I default on my obligation under this Voluntary Repayment Agreement, the DoD shall be entitled to terminate this agreement without
notice. Upon termination, DoD shall retain all amounts paid. Any unpaid balance of my discounted debt will be transferred to the Department of the
Treasury for collection pursuant to title 32 of the Code of Federal Regulations, part 900 – 904. The DoD shall be entitled to take any lawful action it
deems appropriate to collect the debt.
4. Change in Financial Circumstances
I understand that if my financial circumstances change which prevent me from complying with this Voluntary Repayment Agreement, I can contact the
phone number on my account statement in order to inquire about my eligibility to make other payment arrangements, or to request a waiver of my debt.
I certify that I have read and understand the terms of this Voluntary Repayment Agreement for payment by installment.

Guarantor Signature

Date

Print Name
(Last Name, First Name)

Account Number
(from your invoice)

Amount Billed
(from your invoice)

FOR OFFICE USE ONLY

Agency Representative
(Last Name, First Name)
Date
Signature of Agency
Representative

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GUARANTOR’S INFORMATION
IMPORTANT – If the patient is a minor under the age of 18, then the person responsible for payment must complete this section
DEPENDENTS
(Please list all dependents living in your household)
For purposes of this form, a dependent is defined as an individual who meets all of the following criteria:
• Resides in the same household as the person completing this form.
• Receives primary financial support (more than 50%) from the person completing this form. This includes, but is not limited to, providing for
food, shelter, clothing, and medical care.
• Is the spouse of the person completing this form; or is a child (biological, adopted, or step-child) of the person completing this form and is
under the age of 18; or is a child of the person completing this form and is under the age of 24 and enrolled as a full-time student at an
accredited educational institution; or is another relative of the person completing this form who is unable to provide for their own basic needs
due to age, disability, or other significant factors.
NAME

AGE

RELATIONSHIP

1
2
3
4
5
6
7
8

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9
10

HOUSEHOLD INCOME FOR THE CURRENT CALENDAR YEAR
Patient (Guarantor)

Spouse

Children (over the age of 15)

Annual Gross Salary
Annual Alimony Received
Annual Child Support Received
Annual Income from Rental Properties
Annual Interest/Dividends
Annual Income from Business
Annual Pension Income
Annual Insurance Annuity
Annual Disability or SSI
Annual Unemployment
Other Annual Income
Other Annual Income
TOTAL INCOME
PENALTY: With knowledge of the penalties for false statement provided by 18 U.S.C. § 1001 ($10,000 fine and/or five years imprisonment) and with
knowledge that this financial statement is submitted by me to affect action by the Department of Defense (DoD) or Department of the Treasury acting
on behalf of the DoD, I certify that I believe the above statement is true and that it is a complete statement of all my income and assets, real and
personal, whether held in my name or by any other.
Guarantor Signature

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FOR INTERNAL USE ONLY
Instructions: DHA Debt Adjudication Office (or Representative) will complete this section to ensure applications are reviewed and
processed timely for the benefit of the patient and for audit purposes.

Determination of Eligibility for MHS Modified Payments
Received by: (Last
Name, First Name)

Date Application Received
Check all that apply

All documents are complete. The application will be processed.
Applicant is eligible for a discount:
(Percent discounted:

Amount owed $

is discounted to $

%)

Applicant is NOT eligible for a discount.

Yes

No

The patient has claimed that the hospitalization/medical services occurred as the result of an action for which another person or
party is responsible. This package has been referred over to the DHA Medical Claims Recovery Office for processing and
recovery.

Documents Missing (indicate missing documents). The application will be returned and not processed due to missing documents.
Federal Income Tax Return, and the box indicating that they did not file is NOT checked.
Last 2 pay stubs, and the individual did NOT certify that they do not receive income.
Voluntary Repayment Form is NOT signed.
DD Form 2569 is NOT on file.
Copy of medical bill.
Other:
PRINT (Last, First Name)

Signature

Date

DRAFT

Medical Care Recovery Act (MCRA) Tracking
All MCRA collections have been processed and the case has now been closed as of:
Signature

DD FORM 3201, 20260130 DRAFT

(date).

Date

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