DD FORM 2642 APR 2007 PREVIOUS EDITION IS OBSOLETE.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 rende....
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How to fill out the DD 2642 online
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
- Press the ‘Get Form’ button to obtain the DD 2642 form and open it in the designated editor.
- Enter the patient's name as it appears on the military ID card, including the last name, first name, and middle initial.
- Input the patient's primary and secondary telephone numbers, making sure to include the area codes.
- 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.
- Check the appropriate box to indicate the patient's relationship to the sponsor, providing details if ‘Other’ is selected.
- Input the patient's date of birth in the format YYYYMMDD.
- Select the appropriate box to indicate the patient's sex, marking either 'Male' or 'Female'.
- Indicate whether the patient's condition is accident-related or work-related by checking the appropriate boxes if applicable.
- In the 'Describe illness, injury or symptoms' section, provide a detailed account of the condition that required treatment, specifying how any injuries occurred.
- Specify whether the patient received care as an inpatient, outpatient, or via pharmacy by checking the corresponding box.
- Enter the sponsor's or former spouse's full name as it appears on their military ID card.
- Input the sponsor's or former spouse's Social Security Number or DoD Benefits Number.
- 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.
- 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.
- 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.
- 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.
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