TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

OMB 0720-0006

The DD-2642, “TRICARE DoD/ CHAMPUS Medical Claim Patient’s Request for Medical Payment” form is used by TRICARE beneficiaries to claim reimbursement for medical expenses under the TRICARE Program (formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

The latest form for TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment expires 2021-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction
0720-0006_SS-A_10.23.2021.docx Supporting Statement A
DD 2642 SSN Justification Memo_For Signature_08.28.2018signed.pdf Supplementary Document
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction

All Historical Document Collections

202110-0720-001 Approved with change	Revision of a currently approved collection	2021-10-25
201808-0720-001 Approved without change	Extension without change of a currently approved collection	2018-08-30
201501-0720-001 Approved without change	Reinstatement without change of a previously approved collection	2015-02-04
200911-0720-006 Approved without change	Reinstatement without change of a previously approved collection	2009-11-16
200606-0720-001 Approved without change	Extension without change of a currently approved collection	2006-06-26
200301-0720-001 Approved without change	Reinstatement with change of a previously approved collection	2003-01-30
199908-0720-001 Approved without change	Extension without change of a currently approved collection	1999-08-04
199608-0720-001 Approved without change	Reinstatement with change of a previously approved collection	1996-08-29
199304-0720-001 Approved without change	New collection (Request for a new OMB Control Number)	1993-04-08