Statement of Personal Injury: Possible Third Party Liability

OMB 0720-0003

OMB 0720-0003

This information is completed by TRICARE beneficiaries suffering from personal injuries and receiving medical care at Government expense. This information is necessary in the assertion of the Government's right to recover under the Federal Medical Care Recovery Act. The data is used in the evaluation and processing of these claims.

The latest form for Statement of Personal Injury: Possible Third Party Liability expires 2022-04-30 and can be found here.


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