PREVIOUS EDITION IS OBSOLETE.
DD FORM 2642, NOV 2018
Page of
1. PATIENT'S NAME (Last, First, Middle Initial)
2. PATIENT'S TELEPHONE NUMBER (Include Area Code)
Primary ( )
Secondary ( )
3. PATIENT'S ADDRESS (Street, Apt. No., City, State, and ZIP Code) 4. PATIENT'S RELATIONSHIP TO SPONSOR (X one)
SELF STEPCHILD
SPOUSE FORMER SPOUSE
NATURAL OR ADOPTED CHILD
OTHER(Specify)
5. PATIENT'S DATE OF BIRTH
(YYYYMMDD)
6. PATIENT'S SEX
(X one)
MALE FEMALE
7. IS PATIENT'S CONDITION (X both if applicable)
If yes, see #7 in section below
ACCIDENT RELATED?
Yes No
WORK RELATED? Yes No
8a. DESCRIBE ILLNESS, INJURY OR SYMPTOMS THAT REQUIRED TREATMENT, SUPPLIES OR
MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED. REFER TO INSTRUCTIONS BELOW.
8b. WAS PATIENT'S CARE (X one)
INPATIENT?
OUTPATIENT?
DAY SURGERY?
PHARMACY?
9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle Initial)
10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY
NUMBER OR DOD BENEFITS NUMBER (DBN)
11. OTHER HEALTH INSURANCE COVERAGE
a. Is patient covered by any other health insurance plan or program to include health coverage available through other family members? For
patients overseas this includes National Health Insurance. If yes, check the "Yes" block and complete blocks 11 and 12 (see instructions
below). If no, you must check the "No" block and complete block 12. Do not provide TRICARE/CHAMPUS supplemental insurance
information, but do report Medicare supplements.
YES
NO
b. TYPE OF COVERAGE (Check all that apply)
(1) EMPLOYMENT (Group)
(3) MEDICARE (5) MEDICARE SUPPLEMENTAL INSURANCE (7) OTHER (Specify)
(2) PRIVATE (Non-Group)
(4) STUDENT PLAN (6) PRESCRIPTION PLAN
INSURANCE
1
INSURANCE
2
c. NAME AND ADDRESS OF OTHER HEALTH INSURANCE
(Street, City, State, and ZIP Code)
d. INSURANCE IDENTIFICATION
NUMBER
e. INSURANCE
EFFECTIVE DATE
(YYYYMMDD)
f. DRUG
COVERAGE?
YES
NO
YES
NO
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.
12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND
AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.
a. SIGNATURE
b. DATE SIGNED
(YYYYMMDD)
c. RELATIONSHIP TO PATIENT
13. OVERSEAS CLAIMS ONLY:
PAYMENT IN US CURRENCY?
No Yes
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 primary telephone number and secondary telephone
number to include the area code.
3. Enter the complete address of the patient's place of residence at the time of
service (street number, street name, apartment number, city, state, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and numbers.
Do not use an APO/FPO address unless the patient was actually residing
overseas when care was provided.
4. Check the box to indicate patient's relationship to sponsor. If "Other" is
checked, indicate how related to the sponsor; e.g., parent.
5. Enter patient's date of birth (YYYYMMDD).
6. Check the box for either male or female (patient).
7. Check box to indicate if patient's condition is accident related, work related
or both. If accident or work related, the patient is required to complete DD
Form 2527, "Statement of Personal Injury - Possible Third Party Liability
TRICARE Management Activity." Download the form at https://tricare.mil/forms.
8a. Describe patient's condition for which treatment was provided, e.g., broken
arm, appendicitis, eye infection. If patient's condition is the result of an injury,
report how it happened, e.g., fell on stairs at work, car accident.
8b. Check the box to indicate where the care was given.
9. Enter the Sponsor's or Former Spouse's last name, first name and middle
initial as it appears on the military ID Card. If the sponsor and patient are the
same, enter "same."
10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN) or Patients
DoD Benefits Number (DBN).
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. If the patient has
supplemental TRICARE/CHAMPUS insurance, do not report. You must, however,
report Medicare supplemental coverage. Block 11 allows space to report two
insurance coverages. If there are additional insurances, report the information as
required by Block 11 on a separate sheet of paper and attach to the claim.
NOTE: All other health insurances except Medicaid and TRICARE/CHAMPUS
supplemental plans must pay before TRICARE/CHAMPUS will pay. With the
exception of Medicaid and CHAMPUS supplemental plans, you must first submit the
claim to the other health insurer and after that insurance has determined their
payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to
this claim. The claims processor cannot process claims until you provide the other
health insurance information.
12. The patient or other authorized person must sign the claim. If the patient is
under 18 years old, either parent may sign unless the services are confidential and
then the patient should sign the claim. If the patient is 18 years or older, but cannot
sign the claim, the person who signs must be either the legal guardian, or in the
absence of a legal guardian, a spouse or parent of the patient. If other than the
patient, the signer should print or type his/her name in Block 12a. and sign the claim.
Attach a statement to the claim giving the signer's full name and address,
relationship to the patient and the reason the patient is unable to sign. Include
documentation of the signer's appointment as legal guardian, or provide your
statement that no legal guardian has been appointed. If a power of attorney has
been issued, provide a copy.
13. If this is a claim for care received overseas, indicate if you want payment in US
currency.
click to sign
signature
click to edit
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