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 (2024 claims)

For claims with dates of service prior to Jan. 1, 2025 ONLY:
Use this document to update your other health insurance information (OHI).

Do NOT use this form to update your 2025 OHI. Instead, go to www.tricare.mil/west. 

• Created: Jan 1, 2025
• Modified: Jan 1, 2025
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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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