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 can be found here.

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