Using Assistive Technology? Click here to change your profile Skip Navigation Skip to Footer

Completing the Claim Form


It's important to provide all necessary information on the claim form. The items below are critical to process your claim. Once you complete your claim form, keep a copy of it and all original invoices and receipts.

Box 1: Patient's Name Enter the Patient's last name, first name and middle initial as it appears on the military ID card. Do not use nicknames.
Box 2: Patient's Telephone number Enter the patient's daytime telephone number and evening telephone number to include the area code.
Box 3: Patient's Address Enter the complete address of the patient's place of residence at the time of service. Be sure to use your overseas APO/FPO mailing address. Using a local U.S. address will result in payment problems.
Box 4: Patient's relationship to Sponsor Check the box to indicate patient's relationship to sponsor. If "Other" is checked, indicate how related to the sponsor; e.g., former spouse.
Box 5: Patient's Date of Birth Enter the Patient's date of birth.
Box 6: Patient's Sex Check the box for either male or female patient.
Box 7: Is Patient's condition

Check box to indicate if patient's condition is accident related, work related or both. If accident or work related, the patient is required to complete DD Form 2527. >>Learn More 
Box 8a: Describe Condition For which Patient Received Treatment, supplies, or Medication Describe patient's condition for which treatment was provided, e.g., broken arm, appendicitis, eye infection. If patient's condition is the result of an injury, report how it happened, e.g., fell on stairs at work, car accident.
Box 8b: Was Patient's Care Check the box to indicate where the care was given.
Box 9: Sponsor's Name Enter the Sponsor's last name, first name and middle initial as it appears on the military ID card. If the sponsor and patient are the same, enter "same."
Box 10: Sponsor's Social Security Number Enter the Sponsor's Social Security Number.
Box 11: Other Health Insurance Coverage

Indicate if you are covered by any other health insurance plan to include coverage available though other family members. (Do not report supplemental health insurance.) >>Learn More
Box 12: Signature of Patient or Authorized person Certifies correctness of Claim and Authorizes Release of Medical or other insurance information The Patient or other authorized person must sign the claim. If the patient is under 18 years old, either parent may sign unless the services are confidential and then the patient should sign the claim. If the patient is 18 years or older, but cannot sign the claim, the person who signs must be either the legal guardian, or in the absence of a legal guardian, a spouse or parent of the patient. If other than the patient, the signer should print or type his/her name in Box 12a and sign the claim. Attach a statement to the claim giving the signer's full name and address, relationship to the patient and the reason the patient is unable to sign. Include documentation of the signer's appointment as legal guardian, or provide your statement that no legal guardian has been appointed. If a power of attorney has been issued, provide a copy.
Box 13: Payment Currency If this is a claim for care received overseas, indicate if you want payment in the local currency.

Note: Payment is available only in some local currencies.

Last Modified:March 5, 2012