Fillable DD Form 2642, TRICARE DoD/CHAMPUS Medical Claim ... - DTIC - dtic
DD FORM 2642 APR 2007 PREVIOUS EDITION IS OBSOLETE. COPY 1 - PATIENT S COPY Adobe Professional 7. 0 2. If the sponsor and patient are the same enter same. DD FORM 2642 BACK APR 2007 11. By law you must report if the patient is covered by any other health insurance to include health coverage available through other family members. - PATIENT S COPY TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT S REQUEST FOR MEDICAL ...
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