Patient Request for Medical Payment (DD Form 2642)

Use this form to file a claim for healthcare you received.

Before submitting your claim to the claims processor, be sure that you have:

Completed all 12 blocks on the form. If not signed, the claim will be returned.
Verified that the sponsor's SSN is correct.
Attached your provider's or supplier's bill which specifically identifies the doctor/supplier that provided your care.
Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance.
Attached DD Form 2527, "Statement of Personal Injury - Possible Third Party Liability Defense Health Agency" if accident or work related. See instruction number 7 on reverse side of form.
Ensured that patient's name, sponsor's name, and sponsor's SSN are on all attachments.
Made a copy of this claim and attachments for your records.

All claims must be filed no later than one year after the services are provided; or for inpatient care, one year from the date of discharge.
If a claim is returned for additional information, it must be resubmitted by the filing deadline, or within 90 days of the notice — whichever date is later.