How to complete DD Form 2642 (the TRICARE claim form)
Short answer: DD Form 2642, "Patient's Request for Medical Payment," is the TRICARE claim form you use when your provider doesn't file for you. Complete every block, attach an itemized bill on the provider's letterhead, sign it, and send it to your claims processor. The current edition (September 2024) has blocks 1 through 13 — three of them apply only to care received overseas.
Before you start
Have these ready: your itemized bill on the provider's letterhead, your sponsor's Social Security number or DoD Benefits Number, and — for care received overseas — your proof of payment. Use the current DD Form 2642; older editions are obsolete.
Block by block
"Overseas only" blocks can be left blank for care received in the U.S.
| Block | What to enter |
|---|---|
| 1. Patient's name | Last, first, middle initial — exactly as it appears on the military ID card. No nicknames. |
| 2. Patient's telephone | Primary and secondary numbers, including area and country code. |
| 3a. Patient's address | Residence at the time of service. Don't use a P.O. Box (except rural routes). |
| 3b. (Overseas only) | State or country where the services were rendered, if different from the address in 3a. |
| 4. Relationship to sponsor | Check one: self, spouse, natural or adopted child, stepchild, former spouse, or other (specify). |
| 5. Date of birth | Patient's date of birth, formatted YYYYMMDD. |
| 6. Sex | Check one. |
| 7. Accident or work related? | Check yes or no for each. If either is yes, you must also attach DD Form 2527. |
| 8a. Describe the illness or injury | The condition treated, in plain terms (e.g., "broken arm," "ear infection"). If an injury, note how it happened. For a prescription, give the health reason. This is where the diagnosis goes if it isn't already on the bill. |
| 8b. Type of care | Check one: inpatient, outpatient, day surgery, or pharmacy. |
| 8c. (Overseas only) | Indicate if the care was telemedicine or urgent care. |
| 9. Sponsor's name | Sponsor's (or former spouse's) name as on the military ID. If the sponsor and patient are the same person, enter "same." |
| 10. Sponsor's SSN or DBN | The sponsor's Social Security number or the patient's DoD Benefits Number. Double-check this — a wrong number is a common cause of rejection. |
| 11. Other health insurance | Check yes or no. If yes, complete the coverage details. Report Medicare supplements, but do not report TRICARE/CHAMPUS supplements. You must file with the other insurer first and attach its explanation of benefits. |
| 12. Signature | Sign (physical signature or Common Access Card) and date it (YYYYMMDD), and note the signer's relationship to the patient. An unsigned claim is returned. |
| 13. (Overseas only) | Choose reimbursement in U.S. dollars or local currency, confirm you paid the provider, and attach proof of payment. |
The itemized bill (where most claims go wrong)
The form is only half the claim — the attached itemized bill is what gets claims rejected for "missing information." It must be on the provider's letterhead and clearly show all of the following:
- The provider's name and address (if more than one provider is on the bill, circle the one who treated you)
- The date of each service
- The place of each service
- A description of each service or supply
- The charge for each service
- The diagnosis — and if it's not on the bill, complete block 8a
A statement showing only a total charge, a canceled check, or a cash-register receipt is not an acceptable itemized bill unless it includes all of the detail above.
Filing for prescriptions
Pharmacy claims need extra detail on the receipt: the patient's name; the name, strength, date filled, days' supply, quantity dispensed, and price of each drug; the NDC for each drug if available; the prescription number; the pharmacy's name and address; and the prescribing physician's name and address.
Before you submit — the checklist
- Every block is completed, and the form is signed (an unsigned form is returned)
- The sponsor's SSN or DBN is correct
- The itemized provider bill is attached
- An explanation of benefits is attached if there's other health insurance or Medicare
- DD Form 2527 is attached if the care was accident- or work-related
- The patient's name, sponsor's name, and sponsor's SSN or DBN are on every attachment
- You've kept a copy of everything for your records
- For overseas care, proof of payment is attached (a canceled check, credit-card receipt, or EFT record)
Deadlines
File within one year of the date of service for care in the U.S. and U.S. territories, and within three years for care received overseas. If a claim is returned for more information, you must resubmit it within the original filing deadline or within 90 days of the notice — whichever is later.
Where to send it
Send the completed form to your claims processor — your regional contractor for care in the U.S., or the overseas claims processor for care abroad (where you can also file online). Confirm the current address on TRICARE's official claims-address page, and see how to file a TRICARE claim for the full list of addresses and online options.
Let the form fill itself out
File My Claim walks you through every block of DD Form 2642 for free and checks that your billing information is complete before you submit — so the form is right the first time. See also the top reasons claims are rejected.
Common questions
What is DD Form 2642?
It's the TRICARE claim form — "Patient's Request for Medical Payment" — that you use to file your own claim when your provider doesn't file one for you.
Do I have to sign DD Form 2642?
Yes. An unsigned claim is returned. A physical signature or Common Access Card (CAC) signature is required in block 12.
Where do I send DD Form 2642?
To your claims processor — your regional contractor for care in the U.S., or the overseas claims processor for care abroad. Overseas, you can also file online through the secure claims portal. Always confirm the current mailing address on TRICARE's official claims-address page.