What is Form DD-2642?
The DD Form 2642, known as the Patient’s Request for Medical Payment, is essential for TRICARE beneficiaries to file medical claims. This form helps individuals request payment for healthcare services received. It must be filled out completely, requiring information in 12 blocks, such as the patient's name, sponsor's Social Security number, provider details, and a copy of the provider's bill. Accurately completing this form is vital to ensure all necessary information is included, facilitating efficient claim processing and minimizing payment delays.
What is Form DD-2642 used for?
Form DD-2642 is essential for TRICARE beneficiaries who need to claim medical expenses. Here’s what it can do for you:
- Filing Reimbursement Claims: Request reimbursement for authorized health care services and supplies.
- Third-Party Liability Claims: Report injuries or illnesses caused by someone else, using diagnosis codes 800-999.
- Non-Network Provider Claims: Claim expenses from non-network or overseas providers.
- Proof of Payment: Validate claims with itemized bills and receipts for reimbursement.
How to fill out Form DD-2642?
- 1
Enter the patient's last name, first name, and middle initial as shown on the military ID card.
- 2
Fill in the patient’s primary and secondary telephone numbers along with the complete address.
- 3
Provide the date, place, and description of each service or supply furnished.
- 4
List the charge for each service and include the diagnosis if not on the bill.
- 5
Include the provider’s name and address, circling the person who provided the service.
- 6
Report any other health insurance coverage and attach the Explanation of Benefits if applicable.
- 7
Attach a readable copy of the provider’s itemized bill.
Who is required to fill out Form DD-2642?
The beneficiaries of TRICARE or their authorized representatives, such as a spouse, parent, or guardian, are responsible for completing Form DD-2642. It is essential for the beneficiary to fill out all 12 blocks and sign the form.
After completion, the form is submitted to TRICARE with relevant documents for reimbursement of medical services and supplies.
When is Form DD-2642 not required?
You do not need Form DD-2642 if your healthcare provider files the claim for you. You also won’t need it for care from a participating provider in your region, as they will submit the claim. If you receive care overseas and your provider doesn't file the claim, you can submit it online through the secure claims portal.
When is Form DD-2642 due?
The deadline for Form DD-2642 is one year from the date of service or one year from the discharge date for inpatient care. For claims made overseas, the due date extends to three years from the date of service. Ensure you submit your claims on time to avoid delays in processing.
How to get a blank Form DD-2642?
To get a DoD-issued blank Form DD-2642, visit our website where we have the form pre-loaded in our editor. Simply click on the Fill Form option to start filling it out. Remember, our platform aids in filling and downloading forms, but not in filing them.
How to sign Form DD-2642 online?
To sign Form DD-2642 online, you must provide a physical wet signature, use a Common Access Card (CAC), or sign elecronically if filing online. After completing the form using PDF Guru, you can download it for your records. Remember to check for the latest updates regarding signing requirements before proceeding, as regulations may change. PDF Guru helps you fill out and download the form, but submission must be done through other means.
Where to file Form DD-2642?
Once you've completed your Form DD-2642, you can submit it by mail or online. For mail, send your claim to the regional claims processor for your area.
If you're overseas, make sure to file with the TOP claims processor. Alternatively, you can submit online via the secure claims portal at www.tricare-overseas.com/beneficiaries/claims/claims-portal-login.
