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TRICARE DoD/CHAMPUS Claim Form Patients Request for Medical Payment (DD Form 2642) Beneficiaries filing their own medical claims must use this form to receive reimbursement from the TOP Claims Processor for TRICARE Covered Services.
608 327 8522
Dd2642 PDFDd2642 instructionsDd2642 formDd2642 fillableDd2642 TRICAREDD Form 2642 downloadTRICARE East claims fax numberTRICARE claims phone number
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Attached an Explanation of Benefits if there is other health insurance, Medicare, or Medicare supplemental insurance. 5. Obtained a Nonavailability Statement if
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