9. Enter the Sponsor s last name first name and middle initial as it same enter same. DD FORM 2642 BACK APR 2003 11. DD FORM 2642 APR 2003 PREVIOUS EDITION IS OBSOLETE. COPY 1 - PATIENT S COPY 2. PATIENT S TELEPHONE NUMBER Include Area Code 3. Contact a CHAMPUS Health Benefits Advisor or TRICARE Management Activity if you need the name and address of your claims processor. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THIS ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE CHAMPUS CLAIMS...
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Please select a version for Fillable DD 2642 form
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