DD Form 2642, TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Instructions
This form contains 62 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Authorization Details | ||
| Date Signed | Date |
Enter the date the form was signed.
|
| Relationship to Patient | Text |
Provide the relationship of the authorized person to the patient.
|
| Description of Illness/Injury | ||
| Illness/Injury Description | Text |
Provide a detailed description of the illness, injury, or symptoms that required treatment, supplies, or medication, including how any injury occurred.
|
| First Other Health Insurance Details | ||
| Insurance Name and Address | Text |
Please provide the name and full address (street, city, state, and ZIP code) of the first other health insurance provider. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance Identification Number | Text |
Please enter the identification number for the first other health insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance Effective Date | Date |
Please provide the effective date of the first other health insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance 1 Drug Coverage: Yes | Checkbox |
Check this box if the first other health insurance provides drug coverage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance 1 Drug Coverage: No | Checkbox |
Check this box if the first other health insurance does not provide drug coverage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Health Insurance Coverage Inquiry | ||
| Yes | Checkbox |
Check this box if the patient is covered by any other health insurance plan or program, including travel insurance or health coverage available through other family members.
|
| No | Checkbox |
Check this box if the patient is not covered by any other health insurance plan or program.
|
| Overseas Care Details | ||
| Telemedicine | Checkbox |
Check this box if the care provided was telemedicine.
|
| Urgent Care | Checkbox |
Check this box if the care received was urgent care.
|
| Telemedicine/Audio | Checkbox |
Check this box if the telemedicine was audio-only and a reason for audio-only care needs to be provided.
|
| Reason for Audio Only | Text |
Provide the reason for using audio-only telemedicine services in the context of overseas care. Fill only if 'Telemedicine/Audio' is 'Yes'.
Depends on:
Telemedicine/Audio
|
| Overseas Claims Coverage Type | ||
| Travel Insurance | Checkbox |
Check this box if the claim is related to coverage provided by travel insurance. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Medicare Advantage | Checkbox |
Check this box if the claim is related to coverage provided by a Medicare Advantage plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| VA Foreign Medical Program | Checkbox |
Check this box if the claim is related to coverage provided by the VA Foreign Medical Program. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Overseas Claims Payment Information | ||
| US Dollar | Checkbox |
Check this box if the payment for overseas claims was or will be made in US Dollars.
|
| Local Foreign | Checkbox |
Check this box if the payment for overseas claims was or will be made in a local foreign currency.
|
| Payment Made to Provider - Yes | Checkbox |
Check this box if you personally made a payment directly to the provider for the services received.
|
| Payment Made to Provider - No | Checkbox |
Check this box if you did not personally make a payment directly to the provider for the services received.
|
| Overseas Services Location | ||
| Overseas Service Location | Text |
Enter the state or country of the physical location where services were rendered, if it is different from the patient's address in 3a.
|
| Patient or Authorized Person Signature | ||
| 12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION. - a. SIGNATURE (Common Access Card or Physical signature required) | Signature | |
| Patient's Address | ||
| Patient's Full Address | Text |
Please provide the patient's full street address, including apartment number, city, state/country, and ZIP code.
|
| Patient's Care Type | ||
| Inpatient Care | Checkbox |
Check this box if the patient received inpatient care, meaning they were admitted to a hospital or facility for an overnight stay.
|
| Outpatient Care | Checkbox |
Check this box if the patient received outpatient care, meaning they were treated at a hospital, clinic, or facility without an overnight stay.
|
| Day Surgery | Checkbox |
Check this box if the patient underwent a surgical procedure that did not require an overnight hospital stay.
|
| Pharmacy Services | Checkbox |
Check this box if the patient received pharmacy services, such as prescription medications or pharmaceutical consultations.
|
| Patient's Condition | ||
| Accident Related - Yes | Checkbox |
Check this box if the patient's condition is related to an accident.
|
| Accident Related - No | Checkbox |
Check this box if the patient's condition is not related to an accident.
|
| Work Related - Yes | Checkbox |
Check this box if the patient's condition is related to work.
|
| Work Related - No | Checkbox |
Check this box if the patient's condition is not related to work.
|
| Patient's Date of Birth and Sex | ||
| Patient's Date of Birth | Date |
Provide the patient's date of birth.
|
| Male | Checkbox |
Check this box if the patient is male.
|
| Female | Checkbox |
Check this box if the patient is female.
|
| Patient's Name | ||
| Patient's Full Name | Text |
Please enter the patient's full name, including their last name, first name, and middle initial.
|
| Patient's Relationship to Sponsor | ||
| Self | Checkbox |
Check this box if the patient is the sponsor themselves.
|
| Stepchild | Checkbox |
Check this box if the patient is the sponsor's stepchild.
|
| Spouse | Checkbox |
Check this box if the patient is the sponsor's current spouse.
|
| Former Spouse | Checkbox |
Check this box if the patient is the sponsor's former spouse.
|
| Natural or Adopted Child | Checkbox |
Check this box if the patient is the sponsor's natural or adopted child.
|
| Other (Specify) | Checkbox |
Check this box if the patient's relationship to the sponsor is not listed, and provide details.
|
| Other Relationship to Sponsor | Text |
Enter the patient's relationship to the sponsor if it is not one of the listed options. Fill only if 'Other (Specify)' is 'Yes'.
Depends on:
Other (Specify)
|
| Patient's Telephone Number | ||
| Primary Telephone Area/Country Code | Text |
Please enter the area code or country code for the patient's primary telephone number.
|
| Primary Telephone Number | Text |
Please enter the patient's primary telephone number.
|
| Secondary Telephone Area/Country Code | Text |
Please enter the area code or country code for the patient's secondary telephone number.
|
| Secondary Telephone Number | Text |
Please enter the patient's secondary telephone number.
|
| Second Other Health Insurance Details | ||
| Second Other Health Insurance Name and Address | Text |
Provide the name and address of the second other health insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Other Health Insurance Identification Number | Text |
Provide the identification number for the second other health insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Other Health Insurance Effective Date | Date |
Provide the effective date of the second other health insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance 2 Drug Coverage: Yes | Checkbox |
Check this box if the second other health insurance provides drug coverage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance 2 Drug Coverage: No | Checkbox |
Check this box if the second other health insurance does not provide drug coverage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Sponsor Information | ||
| Sponsor's/Former Spouse's Full Name | Text |
Provide the complete name of the sponsor or former spouse, including last name, first name, and middle initial.
|
| Sponsor's/Former Spouse's SSN or DBN | Text |
Enter the Social Security Number (SSN) or Department of Defense Benefits Number (DBN) for the sponsor or former spouse.
|
| Type of Other Coverage | ||
| EMPLOYMENT (Group) | Checkbox |
Check this box if the other health insurance coverage is an employment group plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| PRIVATE (Non-Group) | Checkbox |
Check this box if the other health insurance coverage is a private, non-group plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| MEDICARE | Checkbox |
Check this box if the other health insurance coverage is Medicare. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| STUDENT PLAN | Checkbox |
Check this box if the other health insurance coverage is a student plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| MEDICARE SUPPLEMENTAL INSURANCE | Checkbox |
Check this box if the other health insurance coverage is Medicare supplemental insurance. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| PRESCRIPTION PLAN | Checkbox |
Check this box if the other health insurance coverage is a prescription plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| OTHER (Specify) | Checkbox |
Check this box if the other health insurance coverage type is not listed and specify the type in the provided space. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Coverage Type | Text |
Please provide the type of other health insurance coverage not listed in the provided options. Fill only if 'OTHER (Specify)' is 'Yes'.
Depends on:
OTHER (Specify)
|