Get Dd 2642 2018-2025

This guide provides users with a comprehensive overview of how to accurately fill out the DD 2642, the TRICARE DoD/CHAMPUS medical claim form, online. Following these steps will help ensure that your claim is processed smoothly and efficiently.

Follow the steps to fill out the DD 2642 form online

1. Press the ‘Get Form’ button to obtain the DD 2642 form and open it in the designated editor.
2. Enter the patient's name as it appears on the military ID card, including the last name, first name, and middle initial.
3. Input the patient's primary and secondary telephone numbers, making sure to include the area codes.
4. Fill in the complete address of the patient's residence at the time of service, ensuring it contains the street number, street name, apartment number if applicable, city, state, and ZIP code.
5. Check the appropriate box to indicate the patient's relationship to the sponsor, providing details if ‘Other’ is selected.
6. Input the patient's date of birth in the format YYYYMMDD.
7. Select the appropriate box to indicate the patient's sex, marking either 'Male' or 'Female'.
8. Indicate whether the patient's condition is accident-related or work-related by checking the appropriate boxes if applicable.
9. In the 'Describe illness, injury or symptoms' section, provide a detailed account of the condition that required treatment, specifying how any injuries occurred.
10. Specify whether the patient received care as an inpatient, outpatient, or via pharmacy by checking the corresponding box.
11. Enter the sponsor's or former spouse's full name as it appears on their military ID card.
12. Input the sponsor's or former spouse's Social Security Number or DoD Benefits Number.
13. Report any other health insurance coverage by indicating whether the patient is covered by another plan and filling in the required details about that coverage.
14. Sign the form in the designated block, ensuring the person's name and relationship to the patient are indicated if signing on behalf of the patient.
15. If applicable, specify if you want payment in U.S. currency and follow the instructions to attach the necessary itemized bill and other required documentation.
16. After filling out all the sections, review the entered information for accuracy, and ensure all necessary attachments are included.

Complete your DD 2642 form online today to ensure timely processing of your medical claim.