DD Form 2642 Instructions: Fill It Out Block by Block

The DD Form 2642 is the claim form TRICARE uses when you file for reimbursement yourself. The September 2024 edition added fields built for overseas claims: a box for the country where you were treated, check boxes for telemedicine and urgent care, new other-insurance options, and a currency choice. TRICARE says its overseas claims processor may accept an older edition, but you should use the latest one when you can.

The pictures below are the real form, filled in with a made-up family living in Germany (the number in block 10 is all zeros), so you can see what each block looks like when it is done. The text follows the form’s own “How to fill out” instructions, page 2 of the PDF.

Before you start. TRICARE’s instructions say to fill out every block and sign the form. The form itself warns that a claim that is not signed will be returned, and asks you to make a copy of the claim and everything you attach.

Blocks 1 to 7: the patient

Blocks 1 to 3. Tap or click a picture to enlarge it.

Block 1: Patient’s name. Last name, first name, middle initial, exactly as it appears on the military ID card. The form says not to use nicknames.

Block 2: Patient’s telephone number. There is room for a primary and a secondary number. Include the area code or the country code. Overseas, that means the country code.

Block 3a: Patient’s address. The complete address of the patient’s residence at the time of the service: street number and name, apartment, city, state or country, and ZIP code. The form says not to use a post office box, except rural routes.

Block 3b: Where the services were rendered (overseas claims only). The state or country where the care physically happened, if it is different from the address in 3a. If you live in Germany and were treated in Germany, you can enter Germany. If you were treated on a trip, enter the country of the clinic.

Blocks 4 to 7.

Block 4: Relationship to the sponsor. Check one box: self, stepchild, spouse, former spouse, natural or adopted child, or other. If you check other, say how the patient is related to the sponsor, for example “parent.” Choose self only when the patient is the sponsor.

Block 5: Date of birth. Written as YYYYMMDD, so March 14, 1985 is 19850314.

Block 6: Sex. Male or female.

Block 7: Is the condition accident related or work related? Check yes or no for each. If either is yes, the patient must also complete DD Form 2527, the Statement of Personal Injury and Possible Third Party Liability, and send it with the claim. The form says you can download it at tricare.mil/forms.

Blocks 8 to 10: the care and the sponsor

Block 8: why the patient needed care and where it was given.

Block 8a: Describe the illness, injury or symptoms. Say, in plain words, why the patient needed care. The form gives examples such as a broken arm, appendicitis or an eye infection. If the condition came from an injury, note how it happened, for example a fall on stairs or a car accident. For a prescription, include the health reason, such as diabetes. The form tells you not to list the services performed, because those are on the itemized bill. Block 8a is required on every claim, whether or not the bill shows a diagnosis, so never leave it empty. TRICARE also lists a short description of the reason for care as a required document.

Block 8b: Was the care inpatient, outpatient, day surgery or pharmacy? Check one.

Block 8c: Overseas claims only. Check telemedicine if the care was received by telemedicine, and urgent care if it was urgent. If a telemedicine visit was audio only, check the audio box and give the reason it was audio only.

Blocks 9 and 10: the sponsor.

Block 9: Sponsor’s or former spouse’s name. Last, first, middle initial, as it appears on the military ID. If the sponsor and the patient are the same person, the form says to write “same.”

Block 10: Sponsor’s Social Security Number or DoD Benefits Number (DBN). Either is accepted. When you are the sponsor, this is your own number. Treat the form as sensitive once this is filled in. The form is marked CUI when filled in.

Block 11: other health insurance

Block 11, parts a to c: any other insurance the patient has.

TRICARE is the last payer, and the law requires you to report other coverage, including coverage available through other family members.

Block 11a: Is the patient covered by any other health insurance? For patients overseas this includes national health insurance. If yes, check yes and complete block 11. If no, you must check no. Do not report TRICARE supplemental insurance, but do report Medicare supplements.

Block 11b: Type of coverage. Check all that apply: employment, private, Medicare, student plan, Medicare supplemental, prescription plan, or other.

Block 11c: Overseas claims only. Check travel insurance, Medicare Advantage, or the VA Foreign Medical Program if they apply.

Block 11, parts d to g: the details of each plan.

Blocks 11d to 11g. For each plan: its name and address, your identification number, the effective date (YYYYMMDD) and whether it covers drugs. The block has space for two plans. If there are more, list them on a separate sheet of paper and attach it.

Attach the other insurer’s explanation of benefits. The form says every other plan except Medicaid and TRICARE supplemental plans must pay first. Submit the claim to the other insurer, wait for its decision, then attach its EOB or work sheet to your TRICARE claim. For care overseas, include the EOB for any part that a travel insurance or Medicare Advantage plan paid. If the VA Foreign Medical Program paid part of the services, include a copy of its EOB. The form states that the claims processor cannot process the claim until you provide the other insurance information.

Blocks 12 and 13: signature, currency and payment

Block 12: signature, date and relationship.

Block 12a: Signature. The patient or another authorized person signs. The form says a physical wet signature or a Common Access Card (CAC) signature is required. Print the form, sign it, and scan it, or sign with your CAC.

Block 12b: Date signed. YYYYMMDD.

Block 12c: Relationship to the patient. Fill this in if someone other than the patient signs.

Who may sign, according to the form:

• If the patient is under 18, either parent may sign, unless the services are confidential. Then the patient should sign.
• If the patient is 18 or older but cannot sign, the signer must be the legal guardian or, if there is none, a spouse or parent.
• If someone other than the patient signs, that person prints or types their name in block 12a and signs. Attach a statement with the signer’s full name and address, their relationship to the patient and the reason the patient cannot sign. Include proof of guardianship, or your statement that no guardian has been appointed. If there is a power of attorney, include a copy.

Block 13 and the proof of payment question.

Block 13: Payment in U.S. dollars or local foreign currency (overseas claims only). Check which one you want to be paid in. See claims in foreign currency.

Did you make payment to the provider? Check yes or no. If yes, attach proof of payment. Our guide to what counts as proof of payment lists the accepted documents.

The attachments, and one detail people miss

The form’s own reminder list says to attach:

• the provider’s itemized bill (see our itemized bill guide),
• proof of payment for out-of-pocket expenses overseas,
• the explanation of benefits from any other insurance,
• DD Form 2527 if the condition is accident or work related, and
• the patient’s name, the sponsor’s name and the sponsor’s SSN or DBN on the attachments. The form’s reminder list asks for this. It is something you write on your own copies, not something a provider’s invoice has to print.

Our claim checklist puts all of this on one page.

Filling it faster

If you would rather not type this out for every visit, PaidTrail fills the DD Form 2642 from your saved details, right in your browser, so your Social Security Number never reaches our servers. You print it, sign it by hand and attach it, exactly as the form requires.