What is DD Form 2642?
Form DD 2642, known as the TRICARE/CHAMPUS Medical Claim Form, is essential for filing claims for medical care under the TRICARE program. This form helps determine eligibility for medical services, assesses the liability of other health insurance, certifies that medical care was received, and authorizes reimbursement for healthcare expenses. Completing this form is vital for beneficiaries to receive the financial support they need for their medical care, ensuring that they are not left burdened by unexpected healthcare costs.
What is DD Form 2642 used for?
Form DD 2642 is essential for TRICARE beneficiaries seeking medical care. Here's what it's used for:
- Eligibility Determination: Establishes your eligibility for TRICARE medical care.
- Liability Certification: Confirms that you received medical care and assesses other insurance responsibilities.
- Reimbursement Authorization: Approves reimbursement for medical services you paid for.
- Third-Party Liability Claims: Reports injuries or illnesses from third parties.
- Non-Network Provider Claims: Claims expenses from providers outside the TRICARE network or overseas.
How to fill out DD Form 2642?
- 1
Fill out all 12 blocks of the form completely.
- 2
Verify the sponsor's SSN is correct.
- 3
Attach your provider's or supplier's bill that clearly identifies the doctor/supplier.
- 4
Attach an Explanation of Benefits if you have other health insurance, Medicare, or Medicare supplemental insurance.
- 5
Attach DD Form 2527 if the condition is accident or work-related.
- 6
Ensure the patient's name, sponsor's name, and sponsor's SSN are on all attachments.
Who is required to fill out DD Form 2642?
Beneficiaries of TRICARE or their authorized representatives, like a spouse, parent, or guardian, are responsible for filling out Form DD 2642. They must complete all required fields and sign to validate the form for reimbursement.
After completion, the form is submitted to TRICARE along with relevant documents for reimbursement. Healthcare providers can file claims for patients, but beneficiaries must submit the form themselves if providers do not.
When is DD Form 2642 not required?
You don't need DD Form 2642 if your healthcare provider files the claim on your behalf. Additionally, if you receive care within the TRICARE network, filing a claim isn't necessary. However, if you get care from a non-participating provider or overseas, you may need to file the form yourself.
When is DD Form 2642 due?
The deadline for DD Form 2642 is one year from the date of service or one year from the discharge date for inpatient care. If you are submitting claims made overseas, the deadline extends to three years from the date of service. Make sure to include all necessary information to ensure your claim is processed efficiently and to avoid payment delays.
How to get a blank DD Form 2642?
To get a blank DD Form 2642, simply visit our website. The Department of Defense issues this form, and we have a blank version ready for you to fill out. Remember, PDF Guru assists in filling and downloading forms, but we do not support filing.
How to sign DD Form 2642 online?
To sign the DD Form 2642, TRICARE/CHAMPUS Medical Claim Form, you'll need a physical wet signature or a Common Access Card (CAC) signature, as handwritten signatures are mandatory. PDF Guru allows you to fill out the form and create simple electronic signatures for forms that accept them, but remember, it doesn't support digital signatures or submission. Always check for the latest updates regarding the form before downloading it for your records.
Where to file DD Form 2642?
To submit Form DD 2642, locate the claims address for your region. If you received care in the U.S. or U.S. territories, send it to the TRICARE For Life contractor.
For overseas care, direct your claim to the address where the treatment occurred. Alternatively, you can file your claims online through TRICARE.
