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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.

Third party liability occurs when someone else (an individual, organization, or business) may have been responsible for your injury or illness. When this is the case, that entity or its insurer may be liable to pay your health insurance claims related to that injury or illness.

When your health care providers submit claims to TRICARE for payment, they must provide information indicating why you were seen. Providers do this by using one or more diagnosis codes which describe your injury or illness. Some diagnosis codes can indicate an injury or illness which may have been caused by a third party. When TRICARE receives claims with these types of diagnosis codes, we mail the DD2527 Third Party Liability Form to patients or sponsors in order to determine how the injury or illness occurred.

Sometimes, TRICARE receives claims that include diagnosis codes that may or may not relate to an injury. A common example is when you have surgery or have a medical complication. So even if you do not think there is any possibility of third party liability, please complete and return the form anyway. Make sure to describe the situation as completely as you can.

If you do not return the DD2527 within 35 days, your medical claim(s) will likely be denied. The provider(s) then at that point may bill you directly for the services provided.

 

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