Get DD 2642 2018-2024

DD FORM 2642 APR 2007 PREVIOUS EDITION IS OBSOLETE. COPY 1 - PATIENT S COPY Adobe Professional 7. 0 2. If the sponsor and patient are the same enter same. DD FORM 2642 BACK APR 2007 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. WHERE TO OBTAIN ADDITIONAL FORMS You may obtain additional claim forms from your claims processor the TRICARE Service Center at the nearest military treatment facility or TRICARE Management Activity 16401 E. Centretech Pkwy. 287 and 1001 provide for 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 situations in which ineligible persons knowingly use an unauthorized Identification Card in filing of a CHAMPUS claim or where providers submit claims for treatment supplies or equipment not rendered to or used for TRICARE DoD/CHAMPUS beneficiaries or where a participating provider bills the beneficiary/patient or sponsor for amounts over the CHAMPUS-determined allowable charge or where a beneficiary/patient or sponsor fails to disclose other medical benefits or health insurance coverage. INCOMPLETE CLAIM FORMS WILL DELAY PAYMENT NONAVAILABILITY STATEMENT REQUIREMENTS If the patient resides within the catchment area of a Military Treatment Facility MTF generally within a 40-mile radius of the MTF you will need to obtain a Nonavailability Statement NAS from the MTF for a hospital admission for mental health that is not a bona fide emergency. Examples of fraud include situations in which ineligible persons knowingly use an unauthorized Identification Card in filing of a CHAMPUS claim or where providers submit claims for treatment supplies or equipment not rendered to or used for TRICARE DoD/CHAMPUS beneficiaries or where a participating provider bills the beneficiary/patient or sponsor for amounts over the CHAMPUS-determined allowable charge or where a beneficiary/patient or sponsor fails to disclose other medical benefits or health insurance coverage. INCOMPLETE CLAIM FORMS WILL DELAY PAYMENT NONAVAILABILITY STATEMENT REQUIREMENTS If the patient resides within the catchment area of a Military Treatment Facility MTF generally within a 40-mile radius of the MTF you will need to obtain a Nonavailability Statement NAS from the MTF for a hospital admission for mental health that is not a bona fide emergency. Without a necessary NAS your claim will be denied. ITEMIZED BILL Ask your provider to complete the HCFA Form 1500 for you. OVERSEAS CLAIMS ONLY 12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND PAYMENT IN LOCAL AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION. CURRENCY a. SIGNATURE b. DATE SIGNED c. RELATIONSHIP TO PATIENT 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. DATE SIGNED c. RELATIONSHIP TO PATIENT 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 daytime telephone number and evening telephone number to include the area code. INSURANCE IDENTIFICATION NUMBER e. INSURANCE EFFECTIVE DATE f. DRUG COVERAGE 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. 13. OVERSEAS CLAIMS ONLY 12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND PAYMENT IN LOCAL AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION. CURRENCY a. SIGNATURE b. DATE SIGNED c. RELATIONSHIP TO PATIENT 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.