Free Printable Tricare Form Dd 2527 Form PRINCIPAL PURPOSE S To collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties
When TRICARE receives claims with these types of diagnosis codes we mail the DD2527 Third Party Liability Form to patients or sponsors in order to determine how the injury or illness occurred Sometimes TRICARE receives claims that include diagnosis codes that may or may not relate to an injury The most recent version of the form commonly referred to as the TRICARE DD Form 2527 was released by the Department of Defense DoD on March 1 2020 with all previous editions being obsolete An up to date fillable DD Form 2527 is available for download and digital filing below or can be found on the Executive Services Directorate website
Free Printable Tricare Form Dd 2527 Form
Free Printable Tricare Form Dd 2527 Form
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INSTRUCTIONS We recently received a claim from you or your medical care provider for medical services required by you your family member that indicate that the patient may have had an illness or injury related to an accident Payment of your claims has been suspended until we receive more information Beneficiaries will receive the Statement of Personal Injury Possible Third Party Liability DD Form 2527 if a claim is received that appears to have TPL involvement The beneficiary must complete and sign this form within 35 calendar days and return the form to the address below
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 5 Attached DD Form 2527 Statement of Personal Injury Possible Third Party Liability TRICARE Management Activity if accident or work related See instruction number 7 on reverse side 6 Ensured that patient s name sponsor s name and sponsor s SSN or DBN are on all attachments 7 Made a copy of this claim and attachments for your records 8
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WPS TRICARE For Life P O Box 7890 Madison WI 53707 7890 Check Claim Status View More Contacts 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 Accessing TRICARE DD forms Due to security settings you may not be able to view certain DD forms in your web browser If you encounter an issue viewing a form in your web browser right click and select Save as to save to your computer You can then open the form using your system s default program for viewing PDFs
TRICARE East Region Claims Attn New Claims PO Box 7981 Madison WI 53707 7981 Fax 608 327 8522 EDI Payer ID TREST preferred method TPL Form DD 2527 TPL requested medical records TRICARE East Region Attn Third Party Liability TPL PO Box 8968 Madison WI 53707 8968 5 Attached DD Form 2527 Statement of Personal Injury Possible Third Party Liability Defense Health Agency if accident or work related See instruction number 7 on reverse side of form 6 Ensured that patient s name sponsor s name and sponsor s SSN are on all attachments 7 Made a copy of this claim and attachments for your records
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https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2527.pdf
PRINCIPAL PURPOSE S To collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties
https://www.tricare4u.com/wps/portal/tdb/tricare4u/contact-us/forms/!ut/p/z1/04_Sj9CPykssy0xPLMnMz0vMAfIjo8ziAzw8zDwMLQx83F3cLQwcfU0MPH1DjY0NAgz1w_Eq8DfXjyJGv5G7gaeHgYGht4G7gYGBo5Gzq1lIoK-xi4URcfoNcABHA-L041EQhd_4cP0ovFaAQgCsAJ8XCVlSkBsaGhphkOnpqKgIAG3so2w!/dz/d5/L2dBISEvZ0FBIS9nQSEh/?urile=wcm%3Apath%3A%2FWPS%2BContent%2BEnglish%2Fcontact-us%2Fforms%2FStatement%2Bof%2BPersonal%2BInjury-Possible%2BThird%2BParty%2BLiability%2B%2528DD%2BForm%2B2527%2529Statement%2Bof%2BPersonal%2BInjury-Possible%2BThird%2BParty%2BLiability%2B%2528DD%2BForm%2B2527%2529
When TRICARE receives claims with these types of diagnosis codes we mail the DD2527 Third Party Liability Form to patients or sponsors in order to determine how the injury or illness occurred Sometimes TRICARE receives claims that include diagnosis codes that may or may not relate to an injury
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Printable DD Form 2527 Fillable
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Free Printable Tricare Form Dd 2527 Form - 5 Attached DD Form 2527 Statement of Personal Injury Possible Third Party Liability TRICARE Management Activity if accident or work related See instruction number 7 on reverse side 6 Ensured that patient s name sponsor s name and sponsor s SSN or DBN are on all attachments 7 Made a copy of this claim and attachments for your records 8
