DD Form 2642 at a glance
What it is: DD Form 2642 is the TRICARE DoD/CHAMPUS Medical Claim, Patient's Request for Medical Payment.
Who signs: The patient or other authorized person must sign the claim.
Use this form if your provider doesn't file a claim for you.
A filled-in DD Form 2642 example: a TRICARE patient files a medical claim
How to fill out DD Form 2642, box by box
1. Patient's name, 2. Patient's telephone number, 3a. Patient's address and 3b. State/country where services were rendered
Enter patient's last name, first name and middle initial as it appears on the military ID Card. Do not use nicknames.
Enter the patient's primary telephone number and secondary telephone number to include the area code and/or country code.
Enter the complete address of the patient's place of residence at the time of service (street number, street name, apartment number, city, state/country, ZIP Code). Do not use a Post Office Box Number except for Rural Routes and numbers.
For overseas claims only, identify the State/Country of where the services were rendered (if different than address in 3a).
4. Patient's relationship to sponsor
Check the box to indicate patient's relationship to sponsor. If "Other" is checked, indicate how related to the sponsor; e.g., parent.
5. Patient's date of birth and 6. Patient's sex
Enter patient's date of birth (YYYYMMDD).
Check the box for either male or female (patient).
8a. Describe patient's condition, 8b. Where the care was given and 8c. Telemedicine
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.
Check the box to indicate where the care was given.
If this claim is for care received overseas, indicate if services were received by telemedicine.
11a. Is patient covered by any other health insurance?
Is patient covered by any other health insurance plan or program to include travel insurance or health coverage available through other family members? If yes, check the "Yes" block and complete blocks 11 and 12. If no, you must check the "No" block and complete block 12.
For patients overseas this includes National Health Insurance.
Do not provide TRICARE/CHAMPUS supplemental insurance information, but do report Medicare supplements.
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.
11b to 11g. Type of coverage and other health insurance information
For the type of coverage, check all that apply: (1) Employment (Group), (2) Private (Non-Group), (3) Medicare, (4) Student plan, (5) Medicare supplemental insurance, (6) Prescription plan, (7) Other (Specify).
Overseas claims only, check all that apply: (1) Travel insurance, (2) Medicare Advantage, (3) VA Foreign Medical Program.
For each insurance, enter the name and address of the other health insurance (street, city, state, and ZIP Code), the insurance identification number, and the insurance effective date (YYYYMMDD).
Drug coverage? YES or NO, for INSURANCE 1 and INSURANCE 2. 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.
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.
Pharmacy specific plans must be reported.
If care is provided overseas you must include EOBs for any portion a travel insurance or Medicare Advantage Plan reimbursed.
If VA Foreign Medical Program (FMP) reimbursed a portion of services you must include a copy of the FMP EOB.
13. Overseas claims only: payment in US or foreign currency? Proof of payment
If this is a claim for care received overseas, indicate if you want payment in U.S. or local foreign currency.
Check the box if you made payment to the provider and ensure proof of payment is attached to claim.
Include proof of payment for all out of pocket expenses/services received overseas.
Before you go
Complete this form and attach an itemized bill, which must be on the provider's billings letterhead.
The bill must include the doctor's or provider's name/address (the one that actually provided your care). If there is more than one provider on the bill, circle his/her name. It must also include the date of each service, the place of each service, a description of each surgical or medical service or supply furnished, and the charge for each service.
The diagnosis should be included on the bill. If not, make sure that you've completed block 8a on the form.
Prescription claims require the name of the patient; the name, strength, date filled, days supply, quantity dispensed, and price of each drug; NDC for each drug if available; the prescription number of each drug; the name and address of the pharmacy; and the name and address of the prescribing physician.
Complete all blocks on the form. If not signed, the claim will be returned.
Common questions about DD Form 2642
What is a DD form 2642?
DD Form 2642 is the TRICARE DoD/CHAMPUS Medical Claim, Patient's Request for Medical Payment. Its principal purpose is to determine eligibility for medical care under the TRICARE program, determine other health insurance's liability, and certify that the medical care was received.
Is there a deadline?
In the United States and U.S. territories, claims must be filed within one year from the date of service, or one year from the date of discharge for inpatient care. The timely filing deadline for overseas claims is three years from the date of service. If a claim is returned for additional information, you must resubmit the claim within that timely filing deadline, or within 90 days of the notice, whichever date is later.
Where do I file it?
Return the completed form to the appropriate claims processor. If you do not know who your claims processor is, visit www.tricare.mil/contactus/callus.
Is there a penalty?
Federal laws 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.
What am I certifying when I sign?
Signature of patient or authorized person certifies correctness of claim and authorizes release of medical or other insurance information.
Sources
[1] DD Form 2642 (SEP 2024), TRICARE DoD/CHAMPUS Medical Claim, Patient's Request for Medical Payment, Department of Defense (the Official source link on this page).
