Forms

You can access commonly used forms below. You need Adobe Acrobat to view the forms.
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Patient Request for Medical Payment (DD Form 2642)

Use this form to file a claim for healthcare you received. (download file | 106 KB)

TRICARE For Life - Other Health Insurance Questionnaire

Use this form to let us know if you have or no longer have other health insurance. (download file | 59 KB)

TRICARE For Life Executor/Executrix of Estate Notification

Used to inform TRICARE For Life of the unfortunate passing of a loved one and to notify us who is handling the estate of the deceased. (download file | 112 KB)

Statement of Personal Injury-Possible Third Party Liability (DD Form 2527)

Use this form to explain if your care is due to an accident caused by someone else. (download file | 70 KB)

Authorization for Disclosure of Medical or Dental Information (DD Form 2870)

Use this form to authorize an individual to release information protected under the Federal Privacy Act. This form is not valid to designate a representative for the Appeals process. (download file | 60 KB)

Appointment of Appeal Representative and Authorization to Disclose Information

Use this form to select a representative for the Appeals process only. (download file | 87 KB)