TRICARE Claims Forms

TRICARE Claim forms can be downloaded from the TRICARE website (links below). Complete the appropriate form and send it to the appropriate claims processor. Use this Tricare page to locate where to file your claim. A claim form should be submitted for each family member even in cases where families have visited the same provider on the same day.

When submitting these forms, all pages of the form must be submitted for the claim to be paid.
  • DD2642-CHAMPUS Claim Form (PDF Format) - Claim form to be used by beneficiaries for filing health care claims
  • Referral for Civilian Medical Care (DD2161). Claim form used to request civilian medical services not available at the military treatment facility (MTF)
  • Prime Travel Reimbursement (SF1164). Claim form for reimbursement for expenditures while on official business to include extended travel benefits under TRICARE Prime.
  • Active Duty Claim Form (5578). Claim form to be used for Active Duty filing dental care expenses using the TRICARE Dental plan.
  • Retiree Dental Claim (10/00) Claim form to be used for retirees filing dental care expenses using the TRICARE Retiree Dental Plan.
  • DD2527-CHAMPUS Claim Form (Statement of Personal Injury) Possible Third-Party Liability. This form is required in the DD Form 2642DD filing process in instances in which a patient's condition is accident related, work related, or both. Either beneficiary or provider may use this form.
  • DD0877 Medical Records Release form used by health care providers to request a beneficiary's medical and/or dental records of specific information.

Note: These forms are in PDF format and must be viewed/printed with the Adobe Acrobat Reader. Full instructions for downloading and installing the reader are available at the download site. Please download the reader if necessary.

For general information about TRICARE, call one of the many toll-free TRICARE information lines found at the TRICARE Contact Us web page.

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