If you Have Health Insurance 

The military hospital or clinic where you received your care will file medical claims on your behalf. Once your insurance company pays your claims, you’ll get a bill for:

• Copays 
• Coinsurance
• Deductibles 
• Nominal fees
• Non-covered services

If you believe these payments will cause you financial difficulty, you can apply to the payment and waiver program. You may be eligible for a discount or waiver.

If you Don’t Have Health Insurance  

You’ll get a bill from the military hospital or clinic where you received care.  If you believe paying this bill will cause you financial difficulty, you can apply to the waiver and payment program. You may be eligible for a discount or waiver.

You may be eligible for a sliding fee discount or catastrophic fee waiver if you meet certain criteria.

Sliding Fee Discount

If your annual household income is at or below 400% of the Federal Poverty Guidelines you might have your medical bill reduced to a nominal fee.  Nominal fees are published annually.

Catastrophic Fee Discount

If your annual household income is greater than 400% of the Federal Poverty Guidelines, you might have your medical bill reduced to a maximum of 5% of your monthly income multiplied by 36 months.

Repayment Plans 

If you’re approved for a discounted medical bill, you can:

• Repay your balance in full, or 
• Repay by installment payments of 12, 24, 36, 48, 60 or 72 months (maximum).  The minimum payment amount allowed is $25 per month. For installment payment eligibility, you must sign the Voluntary Repayment Agreement of the DD Form 3201.

You must apply for the waiver and payment program within 90 days of the date on your medical invoice from the military hospital or clinic.

Follow these steps to apply for a reduced or waived medical bill.

1. Complete and submit the following forms:
   o DD Form 3201, “Application for Military Health System Modified Payment and Waiver Program”.
   o DD Form 2569 “Third Party Collection Program/Medical Services Account/Other Health Insurance”. You must complete this form even if you don’t have health insurance.
2. In addition, you must also submit:
   o A copy of your most recent filed Federal Income Tax Return
   -- If you didn’t file a Federal Income Tax return for the preceding year, you must attest that you didn’t file an income tax statement on the application form.  
   o Your last two pay stubs.  
   -- If you don’t have any verifiable income, you must certify that on the application form.  
   o If you’ve certified to having no verifiable income and don’t have either a tax return or pay stubs, you can validate your income by submitting:
   -- Last two bank statements (savings and/or checking accounts),
   -- Disability check stubs, or 
   -- An income verification letter signed by your employer.
3. Mail your application and required documents to the address on your military hospital or clinic’s medical invoice.