Bring your military ID and TRICARE enrollment card to every appointment

Ensure your DEERS record is current before seeking care

If you need specialty care outside the MTF, you will need a referral from your PCM

Military / TRICAREmoderate

TRICARE DoD/CHAMPUS Medical Claim

DD Form 2642 · Department of Defense

TRICARE medical claim form for beneficiaries seeking reimbursement when providers do not file claims directly. Must attach itemized bill on provider letterhead. Used by active duty, retirees, and family members.

Form Details

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Where to Submit This Form

🏢

Submit to the military treatment facility (MTF) Patient Administration office

This form is used by TRICARE beneficiaries to request or verify eligibility for care at military hospitals.

📬

Mail to your regional TRICARE contractor

Find your regional contractor at TRICARE.mil.

Required Attachments

📎 Valid military ID (CAC or dependent ID card)
📎 Current TRICARE enrollment documentation
📎 Referral from primary care manager (if applicable)

Processing Time

Typically processed within 1-3 business days at the MTF.

What Happens Next

The Patient Administration office will verify eligibility and schedule the requested services. You will receive confirmation of the appointment or referral.

Tips for This Form

✓ Bring your military ID and TRICARE enrollment card to every appointment
✓ Ensure your DEERS record is current before seeking care
✓ If you need specialty care outside the MTF, you will need a referral from your PCM

More Military / TRICARE Forms

TRICARE Enrollment (milConnect/DEERS)

Online enrollment · Defense Health Agency

Enrollment in TRICARE plan options (Prime, Select, etc.) through milConnect or DEERS update. Requires valid military ID.

DEERS Enrollment Application

DD Form 1172-2 · Department of Defense

Application for Department of Defense Common Access Card (CAC) or DEERS Enrollment. Establishes beneficiary status for TRICARE eligibility.

TRICARE Referral / Pre-Authorization Request

Contractor-specific · TRICARE managed care contractors

Referral or prior authorization for specialty care, certain procedures, and medications under TRICARE Prime. Not required for TRICARE Select.

TRICARE Pharmacy Prior Authorization

Express Scripts PA form · Express Scripts (TRICARE pharmacy contractor)

Prior authorization for non-formulary medications or formulary drugs with utilization management requirements under TRICARE.

Post-Deployment Health Assessment

DD Form 2796 · Department of Defense

Post-Deployment Health Assessment completed by service members within 30 days of returning from deployment. Screens for deployment-related health concerns including mental health, environmental exposures, and injuries.

Post-Deployment Health Reassessment

DD Form 2900 · Department of Defense

Post-Deployment Health Reassessment completed 90-180 days after return from deployment. Follow-up screening for emerging health issues including PTSD, TBI, and other delayed-onset conditions.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Department of Defense or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.