Get Printable Dd Form 2642 Tricare '

Completing the Printable DD Form 2642 Tricare is an essential step in requesting medical payment. This guide will help you through each section of the form, ensuring that your application is accurate and complete for processing.

Follow the steps to accurately fill out the Printable DD Form 2642 Tricare

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's name in the format of Last, First, and Middle Initial. Ensure that the name matches what is on the military ID card.
3. Provide the patient's telephone number, including area codes for both daytime and evening contacts.
4. Fill in the patient's address, including street, apartment number (if applicable), city, state, and ZIP code.
5. Check the appropriate box to indicate the patient's relationship to the sponsor, selecting from options such as self, spouse, natural or adopted child, stepchild, or other.
6. Input the patient’s date of birth in the format YYYYMMDD.
7. Indicate the patient’s sex by checking either male or female.
8. Assess whether the patient’s condition is accident-related, work-related, or both, marking the respective checkboxes.
9. In block 8a, describe the condition for which the patient received treatment, indicating how any injury occurred if relevant.
10. In block 8b, specify whether the care was provided as inpatient or outpatient.
11. Fill in the sponsor's name, as it appears on their military ID card. If the patient and sponsor are the same, simply write 'same'.
12. Enter the sponsor's Social Security Number (SSN) in the designated field.
13. Report any other health insurance coverage the patient may have, checking yes or no, and completing additional details as necessary.
14. Ensure the claim is signed by the patient or an authorized person, noting the date signed and their relationship to the patient.
15. After completing all necessary blocks, save changes and choose to download, print, or share the form.

Complete your printable DD Form 2642 Tricare online to ensure a smooth medical claim process.