DD Form 2642: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

DD Form 2642 PDF Details

In the United States and territories, claims must be filed within one year from the date of service, or one year from the date of discharge for inpatient care.

Overseas claims: the timely filing deadline for overseas claims is three years from the date of service.

Returned: if a claim is returned for additional information, you must resubmit within the timely filing deadline, or within 90 days of notice, whichever date is later.

Itemized bill: complete this form and attach an itemized bill which must be on the provider's billings letterhead.

Signature: the patient or other authorized person must sign the claim. Physical wet signature or Common Access Card (CAC) is required.