DDFORMS.ORG – DD Form 2642 – CHAMPUS Claim Patient’s Request for Medical Payment – The Department of Defense (DOD) Form 2642, also known as CHAMPUS Claim Patient’s Request for Medical Payment, is a form used to request medical payment from the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). CHAMPUS is a health care program that provides benefits to eligible family members of active duty personnel, retirees, and other qualified individuals.
Download DD Form 2642 – CHAMPUS Claim Patient’s Request for Medical Payment
|Form Number||DD Form 2642|
|Form Title||CHAMPUS Claim Patient’s Request for Medical Payment|
|File Size||90 KB|
What is a DD Form 2642?
A DD Form 2642, also known as the CHAMPUS Claim Patient’s Request for Medical Payment, is an official document used by the military to make medical payments on behalf of beneficiaries. This form is used by families and individuals who are covered under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) in order to receive medical treatment or services from civilian healthcare providers. It contains information such as patient name, date of birth, type of service received, amount requested for payment, provider’s name and address, and more. The document must be completed accurately and signed by both the beneficiary and provider in order for payment to be issued. Once submitted with all necessary supporting documentation to a CHAMPUS office, it can take several weeks for processing before any benefits can be paid out.
Where Can I Find a DD Form 2642?
If you’re looking for the DD Form 2642, commonly known as the CHAMPUS Claim Patient’s Request for Medical Payment, you’ve come to the right place. The DD Form 2642 is required to be filled out and submitted when filing a claim with the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). This form is used to provide information about medical services or supplies that have been given to a CHAMPUS beneficiary so that payment can be requested through CHAMPUS.
The DD Form 2642 enables claimants to provide necessary information about their medical expenses so that they can be processed and paid by CHAMPUS. It also allows them to identify which services or supplies were provided at no cost and should not be included in any claims. The form must be completed in full before it can be submitted for reimbursement.
DD Form 2642 – CHAMPUS Claim Patient’s Request for Medical Payment
DD Form 2642 is a document used by the Department of Defense (DoD) for patients enrolled in CHAMPUS, or Civilian Health and Medical Program of the Uniformed Services. It serves as a request for payment of medical services rendered to an eligible beneficiary. The form can be filled out either by hand or online using DoD-approved software.
The form itself is split up into two sections: Section I provides information on who is filing the claim, including patient name, address, date of birth, and Social Security number; while Section II contains details about the care that was provided such as diagnosis codes, dates of service, fees and whether any insurance was involved. Additionally, it requires beneficiaries to sign off on their agreement with the proposed charges before they can be submitted.
DD Form 2642 Example