OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

OMB 0720-0006 · DOD/DODOASHA.

OMB 0720-0006

The DD2642, “TRICARE DoD/ CHAMPUS Medical Claim Patient’s Request for Medical Payment” form is used by TRICARE beneficiaries to claim reimbursement for medical expenses under the TRICARE Program (formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

The latest form for TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment expires 2028-02-29 and is listed under ICR 202412-0720-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical PaymentForm and Instruction
0720-0006_SS-A_12.27.2024.docxSupporting Statement A
DD 2642 SSN Justification Memo_For Signature_08.28.2018signed.pdf Supplementary Document
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202412-0720-001 Extension without change of a currently approved collection 2024-12-27
202110-0720-001 Revision of a currently approved collection 2021-10-25 Approved with change
201808-0720-001 Extension without change of a currently approved collection 2018-08-30 Approved without change
201501-0720-001 Reinstatement without change of a previously approved collection 2015-02-04 Approved without change
200911-0720-006 Reinstatement without change of a previously approved collection 2009-11-16 Approved without change
200606-0720-001 Extension without change of a currently approved collection 2006-06-26 Approved without change
200301-0720-001 Reinstatement with change of a previously approved collection 2003-01-30 Approved without change
199908-0720-001 Extension without change of a currently approved collection 1999-08-04 Approved without change
199608-0720-001 Reinstatement with change of a previously approved collection 1996-08-29 Approved without change
199304-0720-001 New collection (Request for a new OMB Control Number) 1993-04-08 Approved without change