Fill Out DD Form 2642 Online
TRICARE Patient's Request for Medical Payment
U.S. Department of Defense
Files a TRICARE claim so a beneficiary can be reimbursed for covered medical care paid out of pocket.
Reviewed July 2026
How it works
- 1
Open the form. The official PDF loads straight into the editor, no download needed first.
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Fill it out in the editor. Click anywhere to type, add checkmarks and place your signature.
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Download your PDF. Save the completed form, ready to print or submit.
DD Form 2642, the TRICARE Patient's Request for Medical Payment, is the claim form TRICARE beneficiaries use to get reimbursed for covered medical care they paid for out of pocket. Most network providers file claims for you, so the form typically comes into play after care from a non-network provider, care received overseas, or any visit where you paid the bill yourself.
You can complete DD Form 2642 in the Universal PDF editor, type the patient and provider information into the official layout, and download a clean, legible PDF to sign and mail with your itemized bill. A typed claim is easier for the claims processor to read, which helps avoid delays caused by unclear handwriting.
When you need DD Form 2642
TRICARE beneficiaries file this form themselves in a few common situations:
- You saw a non-network provider who does not file TRICARE claims
- You received care overseas and paid the provider directly
- You paid out of pocket and need TRICARE to reimburse its share
- A pharmacy or provider asked you to submit the claim yourself
Who uses the form
Any TRICARE beneficiary can file it: active duty family members, retirees and their families, National Guard and Reserve members with TRICARE coverage, and TRICARE For Life beneficiaries. A parent or guardian files on behalf of a child, and the sponsor's information is required on the form to link the claim to the right coverage.
Universal PDF is an independent document tool and is not affiliated with TRICARE, the Defense Health Agency, or the Department of Defense.
How to fill out DD Form 2642
Have the itemized bill from your provider in front of you before you start; most of the claim data comes directly from it. Then work through the form:
- Patient information: name, date of birth, address, and relationship to the sponsor
- Sponsor information: the service member's or retiree's name and ID information
- Other health insurance: whether another plan paid first, which affects how TRICARE processes the claim
- The care received: attach the provider's itemized bill showing dates of service, diagnosis, procedures, and charges
- Proof of payment if you are requesting reimbursement for amounts you already paid
- Signature and date at the bottom of the form
Where to send the claim and the deadlines
Mail the signed form with your attachments to the TRICARE claims processor for your region. The current mailing addresses for the East and West regions, the overseas claims process, and the TRICARE For Life contractor are listed on tricare.mil, and the address depends on where you live and which plan you use.
Deadlines matter: TRICARE requires stateside claims to be filed within one year of the date of service, and overseas claims within three years. Most claims are processed within about 30 days, and you can check status through your regional contractor.
Frequently asked questions
Yes. Open it in the Universal PDF editor, type the patient, sponsor, and insurance information on screen, and download the finished PDF. Print and sign it, then mail it with your itemized bill to your regional claims processor.
An itemized bill from the provider showing the dates of service, the diagnosis, each service or procedure with its charge, and the provider's details. If you already paid and want reimbursement, include proof of payment. Claims without an itemized bill are typically returned.
Claims for care received in the United States and its territories must be filed within one year of the date of service. Claims for care received overseas must be filed within three years. Filing promptly after the visit is the safest approach.
It goes to the claims processor for your TRICARE region, not to your local clinic. The East Region, West Region, overseas, and TRICARE For Life claims addresses are published on tricare.mil, so confirm the current address for your plan before mailing.
Usually not. TRICARE network providers file claims on your behalf as part of their agreement. You file DD Form 2642 yourself mainly for non-network care, overseas care, or situations where you paid the provider directly.
TRICARE claims processors handle most claims within about 30 days. Complete, legible claims with the itemized bill attached move fastest, which is a good reason to type the form rather than handwrite it.
Related forms
Universal PDF is an independent product and is not affiliated with or endorsed by any government agency. Forms are provided from official government sources; always confirm you have the current version before filing.