Start here if you have been told to submit DD Form 2642. First, know what you are filling: CHAMPUS Claim Patient's Request for Medical Payment. The document is titled TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT.
Your second step is the edition, not stated, listed as not stated. Your third is scope. Because the number carries a DD prefix, you use the same blank as every other military department and defense agency; no service-specific version exists for you to hunt down.
Once you know the form fits, find out when you file it. not stated sets the requirement, and not stated maintains the form itself. Your own command or agency adds local timing on top of that, so ask your administrative office if the deadline matters to you.
Before you download, pick your approach — editable file or printed page. What follows covers the formats first, then the entries, then what you do afterward.
Now fill it in. Work from the top of the page downward, and do not jump ahead — the identifying block comes first, the substance of your entry second, the certification last. Later boxes often depend on what you put at the top.
Check the edition before you type a word. The date appears on the face of the form; it should read not stated. When it does not, discard the file and take a fresh copy from this page. Department-level revisions replace the blank across all services simultaneously, which means an old printout can be out of step everywhere.
Take the fields in order and answer all of them. Mark inapplicable items N/A instead of leaving white space. When you reach a date, copy the format shown on the form, since a reviewer reading a different convention may misread your entry entirely.
When you reach a Privacy Act Statement, read it before you continue. It tells you the legal authority for collecting your information, what the Department does with it, who else may see it, and whether you have to answer at all. That last point is worth knowing before you supply personal identifiers, not after.
Sign last, and sign properly. On paper that means ink in the signature block. Electronically it means a digital signature, usually applied with your Common Access Card in a reader that supports it. Typing your name into the field does not sign anything. Then add the date beside your signature — an unsigned or undated form is the most common reason one comes back.
Then check your work against the usual failures: an obsolete edition, empty required boxes, handwriting nobody can read after scanning, wrong date format, missing signature or date.
For questions about a specific entry, check the form's own instructions, and if that does not settle it, open not stated. The directive controls where they differ.
Download the form
Step one is picking the format. You have PDF to choose from, across 1 pages, with approximately 100 fields to complete.
Take the pdf if you are unsure. Then check which kind you have: if the boxes highlight when you click them, you have a fillable pdf and can type straight into it, and your entries save with the file. If nothing highlights, you have a printable pdf — send it to a printer and use black ink.
Prefer typing over writing. Your form will likely be scanned and emailed onward, and typed text reproduces at every stage while pen strokes fade or blur. When you do write, print in capitals so the receiving clerk can read it.
What the form asks for
- Address
- Block12A
- CheckBox1
- CheckBox2
- CheckBox3
- CheckBox4
- CheckBox5
- CheckBox6
- CheckBox7
- CheckLeft
- CheckRight
- Checks
- ContentArea
- CurrentPage
- DateField
- DateField1
- Draft
- FifthRow
- FirstRow
- Footer
- FormNumber_Date
- FourthRow
- Frame
- Ins1
With the form finished, route it to the office named in not stated or in your organization's own instruction. Keep a copy first. People rarely regret having one and frequently regret not having one.
When DD Form 2642 references another form, search on the series and number. Because DD numbers are common to every military department, the number by itself identifies exactly one document.
Be careful when a procedure pairs this form with a service form. Read the prefix, not just the digits. Service forms answer to a service proponent, while DD forms answer to not stated or an equivalent Department office, and the two sequences were never aligned. Grabbing the wrong prefix gets you a form that has nothing to do with your task.
Plan to repeat this step whenever the form comes up again. Revisions follow directive changes, changes in what data is collected, and updates to notice language. Since nobody notifies you, check not stated at download and you have covered it.
Before you go, note what is not covered here. You have the blank form and instructions for completing it; you do not have legal guidance, and no statement on this page determines what any office will do with your submission. Direct those questions to not stated, to the personnel office that serves you, or to the office designated in not stated.
Questions and answers
- What is DD Form 2642?
- TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?