Dd Form 2527 PDF Details

In the realm of healthcare, particularly for individuals serving in the military and their families, navigating the complexities of medical costs related to injuries can be cumbersome. Enter the DD Form 2527, titled "Statement of Personal Injury - Possible Third Party Liability." This document plays a pivotal role in the Defense Health Agency's process of determining third-party liability for medical expenses arising from personal injuries. It's designed to collect essential information required to ascertain when third parties, such as insurers or at-fault parties in accidents, may be held responsible for the costs of medical care. The form not only facilitates the recovery of medical expenses by TRICARE, the healthcare program serving uniformed service members, retirees, and their families, but also ensures that healthcare claims are processed efficiently. The completion and submission of DD Form 2527, which involves detailing the nature of the injury, the incident leading to it, and any potential third parties involved, are mandatory steps for claimants. Failure to provide this information might result in delayed or denied claims. The form underscores the importance of transparency and accuracy in reporting injuries, not only for the sake of reimbursement but also as a procedural step that can aid individuals in managing the aftermath of accidents or injuries more effectively.

QuestionAnswer
Form NameDd Form 2527
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdd form 2527 printable, tricare tpl form, tricare dd form 2527, dd form 2527

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STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY

DEFENSE HEALTH AGENCY

OMB No. 0720-0003 Exp.: 30 Apr 2022

IF A PREADDRESSED ENVELOPE IS NOT ENCLOSED WITH THIS FORM, PLEASE RETURN YOUR COMPLETED FORM TO EITHER OF THESE LOCATIONS:

(1)THE TRICARE PROCESSOR WHO SENT YOU THE FORM; OR

(2)THE TRICARE CLAIMS PROCESSOR FOR THE STATE/COUNTRY IN WHICH YOU RECEIVED THE MEDICAL CARE (the Health Benefits Advisor at your nearest military installation can provide you with this address).

The public reporting burden for this collection of information, 0720-0003, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 C.F.R. 199 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties.

ROUTINE USE(S): Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Collected information may also be shared with entities including the Departments of Health and Human Services, Veterans Affairs, Department of Justice, and other Federal, State, local, or foreign government agencies, or authorized private business entities for matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of TRICARE.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases.

For a full listing of the applicable Routine Uses for this system, refer to the applicable SORN.

APPLICABLE SORN: EDTMA 04, Medical/Dental Claim History Files (October 27, 2015, 80 FR 65720 https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/

DISCLOSURE: Voluntary. However, failure to provide information may result in a delay processing your claim(s) and/or the denial of your claim(s).

INSTRUCTIONS

We recently received a claim from you or your medical care provider for medical services required by (you/your family member) that indicate that the patient may have had an illness or injury related to an accident.

Payment of your claims has been suspended until we receive more information. Your claims, and any related claims that are subsequently received, will be denied if this form is not completed and returned within 35 days from the date of this letter.

This information is requested solely for the purpose of processing your TRICARE claim. It has no bearing on any legal action you may pursue as a result of your injury. All questions you may have concerning possible legal actions should be referred to an attorney. Do not execute a release or settle any personal injury claim you may have without notice to a military claims officer.

DD FORM 2527, MAR 2020

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 2

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY

DEFENSE HEALTH AGENCY

Please fill out this form to permit the United States to recover medical expenses from whoever caused your injury. Processing of your TRICARE claim will be suspended until you complete and return this form in the attached self-addressed envelope. Address questions to any

Judge Advocate office or call toll free telephone number

1-800-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I - GENERAL INFORMATION

 

 

 

 

 

 

 

1. SPONSOR'S SOCIAL SECURITY NUMBER:

 

ARMY

 

 

 

NAVY

AIR FORCE

 

 

COAST GUARD

USPHS

NOAA

2. A. INJURED PATIENT'S NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. INJURED PATIENT'S ADDRESS:

 

 

 

 

 

 

C. TELEPHONE

 

 

 

 

 

 

 

 

3. DATE INJURY OCCURED (YYYYMMDD)

 

 

 

 

 

APPROXIMATE TIME OF INJURY:

 

 

 

 

 

 

 

 

4. LOCALITY AND STATE WHERE INJURY OCCURRED:

 

 

 

 

 

 

 

SECTION II - TYPE AND CAUSE OF INJURY

5.TRAFFIC ACCIDENT. (Give name of at-fault driver and insurance company name. If you were a passenger in the accident vehicle, give name of driver and driver's insurance company.)

6.SLIP/FALL, DOG BITE, MISHAP. (Give name of employer, business, municipality, or homeowner where injury occurred.)

7.EXPLOSION. (Specify type of explosive, name and address of place where injury occurred.)

8.ASSAULT. (Give name(s) of person(s) who assaulted you, and responding police department.)

9.TOXIC SUBSTANCE. (Specify substance or drug name, and place where the incident occurred.)

10.ON-THE-JOB INJURY. (Give name and address of employer, and cause of injury.)

11.PRODUCT MALFUNCTION. (Give product name and place where the injury occurred.)

12.MEDICAL MALPRACTICE. (Give date you first knew of the malpractice, doctor's name, and place where the malpractice occurred.)

13.OTHER TYPE AND CAUSE OF INJURY. (Specify.)

SECTION III - MISCELLANEOUS

14. LIST OF MILITARY MEDICAL FACILITIES THAT PROVIDED CARE FOR THIS INJURY, AND DATES OF TREATMENT:

15. HAVE YOU HIRED A LAWYER TO REPRESENT YOU REGARDING THIS INJURY?

YES

NO

 

 

A. LAWYER'S NAME AND ADDRESS:

B. LAWYERS TELEPHONE NUMBER:

 

 

 

16. DO YOU HAVE INSURANCE?

YES

NO

 

 

A. NAME OF INSURANCE PROVIDER(S):

B. INSURANCE TELEPHONE NUMBER(S):

 

 

 

17. YOUR SIGNATURE

 

18. DATE SIGNED (YYYYMMDD)

DD FORM 2527, MAR 2020

Page 2 of 2

 

PREVIOUS EDITION IS OBSOLETE.

How to Edit Dd Form 2527 Online for Free

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You will have to enter the next details to be able to fill out the template:

part 1 to writing dd form 2527 pdf

Write the expected particulars in the EXPLOSION Specify type of, ASSAULT Give names of persons who, TOXIC SUBSTANCE Specify substance, ONTHEJOB INJURY Give name and, PRODUCT MALFUNCTION Give product, MEDICAL MALPRACTICE Give date you, OTHER TYPE AND CAUSE OF INJURY, SECTION III MISCELLANEOUS, and LIST OF MILITARY MEDICAL section.

dd form 2527 pdf EXPLOSION Specify type of, ASSAULT Give names of persons who, TOXIC SUBSTANCE Specify substance, ONTHEJOB INJURY Give name and, PRODUCT MALFUNCTION Give product, MEDICAL MALPRACTICE Give date you, OTHER TYPE AND CAUSE OF INJURY, SECTION III  MISCELLANEOUS, and LIST OF MILITARY MEDICAL fields to insert

It is necessary to put down some details in the area HAVE YOU HIRED A LAWYER TO, YES, A LAWYERS NAME AND ADDRESS, B LAWYERS TELEPHONE NUMBER, DO YOU HAVE INSURANCE, A NAME OF INSURANCE PROVIDERS, YES, B INSURANCE TELEPHONE NUMBERS, YOUR SIGNATURE, DATE SIGNED YYYYMMDD, DD FORM MAR, PREVIOUS EDITION IS OBSOLETE, and Page of.

part 3 to finishing dd form 2527 pdf

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