Prescribed by: TRICARE Reimbursement Manual 6010.

61-M,
April 2015 & TRICARE Operations Manual 6010.59-M, April 2015
CUI (when filled in)

TRICARE DoD/CHAMPUS MEDICAL CLAIM OMB No. 0720-0006

OMB approval expires
PATIENT'S REQUEST FOR MEDICAL PAYMENT 20241231
The public reporting burden for this collection of information, 0720-0006, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-
alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing
to comply with a collection of information if it does not display a currently valid OMB control number.
RETURN COMPLETED FORM TO THE APPROPRIATE CLAIMS PROCESSOR. IF YOU DO NOT KNOW WHO YOUR CLAIMS PROCESSOR IS,
PLEASE VISIT: www.tricare.mil/ContactUs/CallUs.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 C.F.R. 199 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and
E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To determine eligibility for medical care under the TRICARE program, determine other health insurance's liability, certify that the
medical care was received, and reimbursement for medical services received are authorized by law.
ROUTINE USE(S): Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).
Collected information may be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or
foreign government agencies, or authorized private business entities. Any protected health information (PHI) in your records may be used and disclosed
generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but
are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases. For a full listing of the applicable Routine
Uses for this system, refer to the applicable SORN.
APPLICABLE SORN: EDTMA 04, Medical/Dental Claim History Files (October 27, 2015, 80 FR 65720); https://dpcld.defense.gov/Privacy/SORNsIndex/
DOD-wide-SORN-Article-View/Article/570707/edtma-04/.
DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed, but absence of the requested information may result in
delay of payment or may result in denial of claim.
FRAUD NOTICE - READ CAREFULLY
Federal Laws (18 U.S.C. 287 and 1001) 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. Examples of fraud include situations in which ineligible
persons knowingly use an unauthorized Identification Card in filing of a TRICARE/CHAMPUS claim; or where providers submit claims for treatment, supplies or
equipment not rendered to, or used for TRICARE DoD/CHAMPUS beneficiaries; or where a participating provider bills the beneficiary/patient (or sponsor) for
amounts over the TRICARE/CHAMPUS-determined allowable charge; or where a beneficiary/patient (or sponsor) fails to disclose other medical benefits or
health insurance coverage.

IMPORTANT - READ CAREFULLY

Use this form if your provider doesn't file a claim for you. If you receive care overseas you can register on the secure claims portal to file your overseas claim
online at www.tricare-overseas.com/beneficiaries/claims/claims-portal-login.

ITEMIZED BILL: Complete this form and attach an itemized bill which must be on the provider's billings letterhead. The bill must include the following
information:

1. 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;
2. Date of each service;
3. Place of each service;
4. Description of each surgical or medical service or supply furnished;
5. Charge for each service;
6. The diagnosis should be included on the bill. If not, make sure that you've completed block 8a on the form.

PRESCRIPTION DRUGS: 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. Billing statements showing only total charges, or canceled checks, or cash register and similar type receipts are not
acceptable as itemized statements, unless the receipt provides detailed information required above.

TIMELY FILING REQUIREMENTS: 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 the timely filing deadline, or within 90 days of the notice - whichever date is later.

WHERE TO OBTAIN ADDITIONAL FORMS: You may obtain additional claim forms by calling your regional contractor (telephone numbers are available at
www.tricare.mil/contactus) or by going to www.tricare.mil, mytricare.com or tricare4u.com.

* * * REMINDER * * *

Before submitting your claim to the claims processor be sure that you have:
1. Completed all blocks on the form. If not signed, the claim will be returned.
2. Verified that the sponsor's SSN is correct.
3. Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.
4. Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.
5. Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity" if accident
or work related. See instruction number 7 on reverse side.
6. Ensured that patient's name, sponsor's name and sponsor's SSN or DBN are on all attachments.
7. Made a copy of this claim and attachments for your records.
8. Included proof of payment for all out of pocket expenses/services received overseas. TRICARE accepts the following as proof of payment: A canceled
check, credit card receipt, or electronic funds transfer (EFT) record showing the beneficiary paid the provider.

DD FORM 2642, SEP 2024 Controlled by: DHA Page 1 of 2

CUI (when filled in) CUI Category: PRVCY
PREVIOUS EDITION IS OBSOLETE. Distribution/Dissemination Control: FEDCON
POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil
 CUI (when filled in)
1. PATIENT'S NAME (Last, First, Middle Initial) 2. PATIENT'S TELEPHONE NUMBER (Include Area/Country Code)
Primary ( )
Secondary ( )
3a. PATIENT'S ADDRESS (Street, Apt. No., City, State/Country, and ZIP Code) OVERSEAS CLAIMS ONLY:
3.b STATE/COUNTRY OF PHYSICAL LOCATION WHERE SERVICES WERE
RENDERED (if different than address in 3a)

4. PATIENT'S RELATIONSHIP TO SPONSOR (X one)

SELF STEPCHILD SPOUSE FORMER SPOUSE
NATURAL OR ADOPTED CHILD OTHER (Specify)
5. PATIENT'S DATE OF BIRTH 7. IS PATIENT'S CONDITION (X both if applicable)
6. PATIENT'S SEX (X one)
(YYYYMMDD) If yes, see #7 in section below
MALE FEMALE ACCIDENT RELATED? Yes No
WORK RELATED? Yes No
8a. DESCRIBE ILLNESS, INJURY OR SYMPTOMS THAT REQUIRED TREATMENT, SUPPLIES OR 8b. WAS PATIENT'S CARE (X one)
REASON FOR MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED (Do not list services INPATIENT? OUTPATIENT?
performed). REFER TO INSTRUCTIONS BELOW. DAY SURGERY? PHARMACY?
8c. OVERSEAS CLAIMS ONLY
TELEMEDICINE? URGENT CARE?
TELEMEDICINE/
AUDIO: reason for
audio only:
9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle Initial) 10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY NUMBER OR
DOD BENEFITS NUMBER (DBN)

11. OTHER HEALTH INSURANCE COVERAGE

a. Is patient covered by any other health insurance plan or program to include travel insurance or health coverage available through other YES
family members? For patients overseas this includes National Health Insurance. If yes, check the "Yes" block and complete blocks 11 and
12 (see instructions below). If no, you must check the "No" block and complete block 12. Do not provide TRICARE/CHAMPUS NO
supplemental insurance information, but do report Medicare supplements.
b. TYPE OF COVERAGE (Check all that apply)
(1) EMPLOYMENT (Group) (3) MEDICARE (5) MEDICARE SUPPLEMENTAL INSURANCE
(7) OTHER (Specify)
(2) PRIVATE (Non-Group) (4) STUDENT PLAN (6) PRESCRIPTION PLAN
c. OVERSEAS CLAIMS ONLY (Check all that apply)
(1) TRAVEL INSURANCE (2) MEDICARE ADVANTAGE (3) VA FOREIGN MEDICAL PROGRAM
e. INSURANCE f. DRUG
c. NAME AND ADDRESS OF OTHER HEALTH INSURANCE d. INSURANCE IDENTIFICATION EFFECTIVE DATE
(Street, City, State, and ZIP Code) NUMBER (YYYYMMDD) COVERAGE?

INSURANCE YES
1 NO
INSURANCE YES
2 NO
REMINDER: 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.
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) b. DATE SIGNED (YYYYMMDD) c. RELATIONSHIP TO PATIENT

13. OVERSEAS CLAIMS ONLY: PROOF OF PAYMENT:

PAYMENT IN US OR FOREIGN US Dollar Local Foreign Did you make payment to provider? YES NO
CURRENCY? REMINDER: Attach proof of payment
HOW TO FILL OUT THE TRICARE/CHAMPUS FORM
You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.
11. By law, you must report if the patient is covered by any other health insurance to include health
1. Enter patient's last name, first name and middle initial as it appears on the military ID Card. Do not
coverage available through other family members. If the patient has supplemental TRICARE/
use nicknames.
CHAMPUS insurance, do not report. You must, however, report Medicare supplemental coverage.
2. Enter the patient’s primary telephone number and secondary telephone number to include the area
Block 11 allows space to report two insurance coverages. If there are additional insurances, report the
code and/or country code.
information as required by Block 11 on a separate sheet of paper and attach to the claim. Pharmacy
3a. Enter the complete address of the patient's place of residence at the time of service (street
specific plans must be reported. NOTE: All other health insurances except Medicaid and TRICARE/
number, street name, apartment number, city, state/country, ZIP Code).
CHAMPUS supplemental plans must pay before TRICARE/CHAMPUS will pay. With the exception of
Do not use a Post Office Box Number except for Rural Routes and numbers.
Medicaid and CHAMPUS supplemental plans, you must first submit the claim to the other health insurer
3b. Identify the State/Country of where the services were rendered.
and after that insurance has determined their payment, attach the other insurance Explanation of
4. Check the box to indicate patient's relationship to sponsor. If "Other" is checked, indicate how
Benefits (EOB) or work sheet to this claim. If care is provided overseas you must include EOBs for any
related to the sponsor; e.g., parent.
portion a travel insurance or Medicare Advantage Plan reimbursed. If VA Foreign Medical Program
5. Enter patient's date of birth (YYYYMMDD).
(FMP) reimbursed a portion of services you must include a copy of the FMP EOB. The claims processor
6. Check the box for either male or female (patient).
cannot process claims until you provide the other health insurance information.
7. Check box to indicate if patient's condition is accident related, work related or both. If accident or
12. The patient or other authorized person must sign the claim. If the patient is under 18 years old,
work related, the patient is required to complete DD Form 2527, "Statement of Personal Injury -
either parent may sign unless the services are confidential and then the patient should sign the claim. If
Possible Third Party Liability TRICARE Management Activity." Download the form at https://
the patient is 18 years or older, but cannot sign the claim, the person who signs must be either the legal
tricare.mil/forms.
guardian, or in the absence of a legal guardian, a spouse or parent of the patient. If other than the
8a. Describe patient's condition for which treatment was provided, e.g., broken arm, appendicitis, eye
patient, the signer should print or type his/her name in Block 12a. and sign the claim. Physical wet
infection. If patient's condition is the result of an injury, report how it happened, e.g., fell on stairs at
signature or Common Access Card (CAC) is required.
work, car accident. Include health reason for prescription needs (e.g. diabetic, hypothyroid).
Attach a statement to the claim giving the signer's full name and address, relationship to the patient and
8b. Check the box to indicate where the care was given.
the reason the patient is unable to sign. Include documentation of the signer's appointment as legal
8c. If this claim is for care received overseas, indicate if services were received by telemedicine.
guardian, or provide your statement that no legal guardian has been appointed. If a power of attorney
9. Enter the Sponsor's or Former Spouse's last name, first name and middle initial as it appears on
has been issued, provide a copy.
the military ID Card. If the sponsor and patient are the same, enter "same."
13. If this is a claim for care received overseas, indicate if you want payment in US or local foreign
10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN) or Patient's DoD Benefits
currency. Check the box if you made payment to the provider and ensure proof of payment is attached
Number (DBN). Note: the sponsor number may be your own SSN.
to claim.

DD FORM 2642, SEP 2024 Page 2 of 2

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.