Form 2642 TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR

CUI/SPII (when filled in)
TRICARE DoD/CHAMPUS MEDICAL CLAIM
PATIENT'S REQUEST FOR MEDICAL PAYMENT

OMB No. XXXX-XXXX
OMB approval expires
XXXXXXXX

The public reporting burden for this collection of information, 0720-0006, is estimated to average 15 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-informationcollections@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.

RETURN COMPLETED FORM TO THE APPROPRIATE CLAIMS PROCESSOR. IF YOU DO NOT KNOW WHO YOUR CLAIMS PROCESSOR IS,
PLEASE VISIT: www.tricare.mil/ContactUs/CallUs.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 C.F.R. 199 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and
E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To determine eligibility for medical care under the TRICARE program, determine other health insurance's liability, certify that the
medical care was received, and reimburse for medical services received as authorized by law.
ROUTINE USE(S): Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).
Collected information may be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or
foreign government agencies, or authorized private business entities. Any protected health information (PHI) in your records may be used and disclosed
generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but
are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases. For a full listing of the applicable Routine
Uses for this system, refer to the applicable SORN.
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 your information, no penalty may be imposed, but absence of the requested information may result in
delay of payment or may result in denial of the claim.
FRAUD NOTICE - READ CAREFULLY
Federal Laws (18 U.S.C. 287 and 1001) provide criminal penalties for knowingly submitting or making any false, fictitious, or fraudulent statement or claim in any
matter within the jurisdiction of any department or agency of the United States. Examples of fraud include, but are not limited to, situations in which: 1) ineligible
persons knowingly use an unauthorized Identification Card in filing a TRICARE/CHAMPUS claim; 2) providers submit claims for treatment, supplies, or
equipment not rendered to, or used for TRICARE DoD/CHAMPUS beneficiaries; 3) a participating provider bills the beneficiary/patient (or sponsor) for amounts
over the TRICARE/CHAMPUS-determined allowable charge; or, 4) a beneficiary/patient (or sponsor) fails to disclose other medical benefits or health insurance
coverage.
IMPORTANT - READ CAREFULLY
Use this form if your provider does not file a claim for you. If you receive care overseas, you can register on the secure claims portal to file your overseas claim
online at www.tricare-overseas.com/beneficiaries/claims/claims-portal-login.
ITEMIZED BILL: Complete this form and attach an itemized bill which must be on the provider's billings letterhead. The bill must include the following
information:
1. Doctor's or provider's name/address (the one that actually provided your care). If there is more than one provider on the bill, circle his/her name;
2. Date of each service;
3. Place of each service;
4. Description of each surgical or medical service or supply furnished;
5. Charge for each service;
6. The diagnosis should be included on the bill. If not, make sure that you have completed block 8a on the form.
PRESCRIPTION DRUGS: Prescription claims require the name of the patient; the name, strength, date filled, days’ supply, quantity dispensed, and price of
each drug; the NDC for each drug if available; the prescription number of each drug; the name and address of the pharmacy; and, the name and address of
the prescribing physician. Billing statements showing only total charges, canceled checks, or cash register and similar type receipts are not acceptable as
itemized statements, unless the receipt provides detailed information required above.
TIMELY FILING REQUIREMENTS: In the United States and U.S. territories, claims must be filed within one year from the date of service, or one year from the
date of discharge for inpatient care. The timely filing deadline for overseas claims is three years from the date of service. If a claim is returned for additional
information, you must resubmit the claim within the timely filing deadline, or within 90 days of the notice - whichever date is later.
WHERE TO OBTAIN ADDITIONAL FORMS: You may obtain additional claim forms by calling your regional contractor (telephone numbers are available at
www.tricare.mil/contactus) or by going to www.tricare.mil, mytricare.com, or tricare4u.com.

* * * REMINDER * * *
Before submitting your claim to the claims processor be sure that you have:
1. Completed all 12 blocks on the form. If not signed, the claim will be returned.
2. Verified that the sponsor's SSN is correct.
3. Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.
4. Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.
5. Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity" if accident or work related.
See instruction number 7 on reverse side.
6. Ensured that patient's name, sponsor's name, and sponsor's SSN or DBN are on all attachments.
7. Made a copy of this claim and attachments for your records.
8. Included proof of payment for all out of pocket expenses/services received overseas. TRICARE accepts the following as proof of payment:
A canceled check, credit card receipt, or electronic funds transfer (EFT) record showing the beneficiary paid the provider.

DD FORM 2642, DRAFT 20210813

CUI/SPII (when filled in)
PREVIOUS EDITION IS OBSOLETE.

Controlled by: DHA
CUI Category: HLTH, FNC
Distribution/Dissemination Control: FEDCON
POC: valerie.a.palmer3.civ@mail.mil

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CUI/SPII (when filled in)
1. PATIENT'S NAME (Last, First, Middle Initial)

2. PATIENT'S TELEPHONE NUMBER (Include Area Code)

3. PATIENT'S ADDRESS (Street, Apt. No., City, State, and ZIP Code)

Primary
(
)
Secondary (
)
4. PATIENT'S RELATIONSHIP TO SPONSOR (X one)

5. PATIENT'S DATE OF BIRTH

SELF

STEPCHILD

SPOUSE

FORMER SPOUSE

NATURAL OR ADOPTED CHILD

OTHER(Specify)

7. IS PATIENT'S CONDITION (X both if applicable)

6. PATIENT'S SEX (X one)

If yes, see #7 in section below

(YYYYMMDD)

MALE

FEMALE

ACCIDENT RELATED?

Yes

No

WORK RELATED?

Yes

No

8a. DESCRIBE ILLNESS, INJURY OR SYMPTOMS THAT REQUIRED TREATMENT, SUPPLIES OR
MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED. REFER TO INSTRUCTIONS BELOW.

8b. WAS PATIENT'S CARE (X one)
INPATIENT?

PHARMACY?

OUTPATIENT?
DAY SURGERY?

9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle Initial)

10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY
NUMBER OR DOD BENEFITS NUMBER (DBN)

11. OTHER HEALTH INSURANCE COVERAGE
a. Is patient covered by any other health insurance plan or program to include health coverage available through other family members?
For patients overseas this includes National Health Insurance. If yes, check the "Yes" block and complete blocks 11 and 12 (see
instructions below). If no, you must check the "No" block and complete block 12. Do not provide TRICARE/CHAMPUS supplemental
insurance information, but do report Medicare supplements.

YES
NO

b. TYPE OF COVERAGE (Check all that apply)
(1) EMPLOYMENT (Group)

(3) MEDICARE

(5) MEDICARE SUPPLEMENTAL INSURANCE

(2) PRIVATE (Non-Group)

(4) STUDENT PLAN

(6) PRESCRIPTION PLAN

c. NAME AND ADDRESS OF OTHER HEALTH INSURANCE
(Street, City, State, and ZIP Code)

d. INSURANCE IDENTIFICATION
NUMBER

(7) OTHER (Specify)
e. INSURANCE
f. DRUG
EFFECTIVE DATE
COVERAGE?
(YYYYMMDD)

INSURANCE
1

YES

INSURANCE
2

YES

NO

NO

REMINDER: Attach your other health insurances's Explanation of Benefits or pharmacy receipt that indicates the actual drug cost, amount the OHI paid,
and the amount that you paid.
12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND
AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.
c. RELATIONSHIP TO PATIENT
a. SIGNATURE
b. DATE SIGNED

13. OVERSEAS CLAIMS ONLY:
PAYMENT IN US CURRENCY?

(YYYYMMDD)

Yes

No

HOW TO FILL OUT THE TRICARE/CHAMPUS FORM
You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.
1. Enter patient's last name, first name and middle initial as it appears on the
military ID Card. Do not use nicknames.
2. Enter the patient's primary telephone number and secondary telephone
number to include the area code.
3. Enter the complete address of the patient's place of residence at the time of
service (street number, street name, apartment number, city, state, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and numbers.
Do not use an APO/FPO address unless the patient was actually residing
overseas when care was provided.
4. Check the box to indicate patient's relationship to sponsor. If "Other" is
checked, indicate how related to the sponsor; e.g., parent.
5. Enter patient's date of birth (YYYYMMDD).
6. Check the box for either male or female (patient).
7. Check box to indicate if patient's condition is accident related, work related
or both. If accident or work related, the patient is required to complete DD
Form 2527, "Statement of Personal Injury - Possible Third Party Liability
TRICARE Management Activity." Download the form at https://tricare.mil/forms.
8a. Describe patient's condition for which treatment was provided, e.g., broken
arm, appendicitis, eye infection. If patient's condition is the result of an injury,
report how it happened, e.g., fell on stairs at work, car accident.
8b. Check the box to indicate where the care was given.
9. Enter the Sponsor's or Former Spouse's last name, first name and middle
initial as it appears on the military ID Card. If the sponsor and patient are the
same, enter "same."
10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN) or Patients
DoD Benefits Number (DBN).

DD FORM 2642, DRAFT 20210813

11. By law, you must report if the patient is covered by any other health insurance to
include health coverage available through other family members. If the patient has
supplemental TRICARE/CHAMPUS insurance, do not report. You must, however,
report Medicare supplemental coverage. Block 11 allows space to report two
insurance coverages. If there are additional insurances, report the information as
required by Block 11 on a separate sheet of paper and attach to the claim.
NOTE: All other health insurances except Medicaid and TRICARE/CHAMPUS
supplemental plans must pay before TRICARE/CHAMPUS will pay. With the
exception of Medicaid and CHAMPUS supplemental plans, you must first submit the
claim to the other health insurer and after that insurance has determined their
payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to
this claim. The claims processor cannot process claims until you provide the other
health insurance information.
12. The patient or other authorized person must sign the claim. If the patient is
under 18 years old, either parent may sign unless the services are confidential and
then the patient should sign the claim. If the patient is 18 years or older, but cannot
sign the claim, the person who signs must be either the legal guardian, or in the
absence of a legal guardian, a spouse or parent of the patient. If other than the
patient, the signer should print or type his/her name in Block 12a. and sign the claim.
Attach a statement to the claim giving the signer's full name and address,
relationship to the patient and the reason the patient is unable to sign. Include
documentation of the signer's appointment as legal guardian, or provide your
statement that no legal guardian has been appointed. If a power of attorney has
been issued, provide a copy.
13. If this is a claim for care received overseas, indicate if you want payment in US
currency.

CUI/SPII (when filled in)
PREVIOUS EDITION IS OBSOLETE.

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