9. Enter the Sponsor s last name first name and middle initial as the same enter same. DD FORM 2642 BACK NOV 1999 11. DD FORM 2642 NOV 1999 PREVIOUS EDITION IS OBSOLETE. COPY 1 - PATIENT S COPY 2. PATIENT S TELEPHONE NUMBER Include Area Code 3. - PATIENT S COPY CHAMPUS CLAIM PATIENT S REQUEST FOR MEDICAL PAYMENT Form Approved OMB No* 0720-0006 Expires Sep 30 2002 The public reporting burden for this collection of...
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