TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)
In most cases your provider will file the claim and you'll get an explanation of benefits showing what was paid. Sometimes, you'll need to file your own claims (i.e. when traveling or getting care from a non-participating provider).
Send the claim form and supporting documents:
- To the appropriate claims address
- Within the specified deadlines:
- U.S. and U.S. Territories—One year of service
- In all other overseas areas—Three years of service
Statement of Personal Injury-Possible Third Party Liability (DD Form 2527)
You'll need to use this form when you submit claims for an injury or illness caused by a third party:
- Diagnosis codes 800-999
- Professional services exceeding $500
- All inpatient services
Medicare Health Insurance Claim Form (Form CMS-1500)
The Form CMS-1500 (formally known as HCFA-1500) is the standard paper claim form used by health care professionals and suppliers for Medicare claims. Medicare claims must be submitted within one year of service.
>>View CMS-1500 Fact Sheet