Claims

Beneficiary Claim Form

Beneficiaries filing their own medical claim must use DD Form 2642. Be sure to attach a copy of the provider’s itemized bill to the claim form.

Tip for Chrome users: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." Once saved locally, you can open the form. 

• Created: Aug 1, 2022
• Modified: Feb 20, 2019
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Other Health Insurance Questionnaire

Use this document to update your other health insurance information.

Tip for Chrome users: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." Once saved locally, you can open the form. 

• Created: Aug 1, 2022
• Modified: Feb 20, 2019
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Statement of Personal Injury – Possible Third Party Liability

Beneficiaries may be asked to complete the Possible Third Party Liability form if the health care services received indicate an accident or injury. Submit it by mail or fax to:

TRICARE West Claims - TPL
PO Box 202103
Florence, SC 29502-2103
Fax: 1-844-869-2813

Tip for Chrome users: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." Once saved locally, you can open the form. 

• Created: Aug 1, 2022
• Modified: Jul 8, 2020
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Costs and Fees (2021)

The TRICARE Costs and Fees Sheet for 2021 lists the costs and fees associated with TRICARE program options, including TRICARE Prime, TRICARE Select, premium-based health care options (TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult), the TRICARE Pharmacy Program, and the TRICARE Dental Program.

• Created: Mar 25, 2021
• Modified: Mar 25, 2021
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