Get Dd Form 2642, "tricare Dod/champus Medical Claim Patient's Request For Medical

Filling out the DD Form 2642 is a crucial step in requesting reimbursement for medical expenses under the TRICARE program. This guide will help users navigate the form with clarity and confidence, ensuring all necessary information is submitted accurately.

Follow the steps to successfully complete the DD Form 2642 online.

1. Click 'Get Form' button to access the DD Form 2642 and open it for editing.
2. Enter the patient's full name as it appears on their military ID card, including any middle initials. Avoid using nicknames.
3. Provide the patient’s primary and secondary telephone numbers, including the appropriate area or country codes.
4. Fill in the patient's complete address at the time of service, specifying the street number, street name, apartment number (if applicable), city, state or country, and ZIP code.
5. If the services were rendered in a different location than the patient's address, indicate the state or country where the services were provided.
6. Select the box that indicates the patient's relationship to the sponsor, ensuring accuracy in selecting options like self, spouse, or child.
7. Indicate the patient's date of birth using the format YYYYMMDD.
8. Choose the appropriate box for the patient's sex, marking either male or female.
9. Identify whether the patient's condition is accident related or work related by selecting the corresponding checkboxes.
10. Provide a detailed description of the illness, injury, or symptoms that necessitated the treatment, including a note on how any injury occurred.
11. Select the appropriate box to denote where the care was provided, such as inpatient, outpatient, or pharmacy services.
12. Enter the sponsor's or former spouse's full name, mirroring the details on their military ID card.
13. Input the sponsor's or former spouse's Social Security Number or DoD Benefits Number.
14. If applicable, report other health insurance coverages in the designated blocks, ensuring to include any details on supplementary insurance.
15. The patient or authorized individual must sign the form, certifying the information provided, and indicating their relationship to the patient.
16. Indicate any desires for payment currency if the claim is for services received overseas.
17. Review the form thoroughly, ensuring all blocks are completed and necessary attachments are included before submitting.

Complete your documents online today to ensure a smooth claims process.