Form Information
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FORM NUMBER: DD2642

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TITLE: TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT

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EDITION DATE: 20070401 CANCELLATION DATE:

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AVAILABLE FILE FORMATS: PLEASE NOTE:
Fillable Adobe: PDF-Ext If no hyperlink appears next to a format, the form is not available electronically. To
Perform Pro: obtain hard copies of current forms not available in electronic format, please contact
Form Flow 2.0: your own Military Service or DoD Component Forms Management Officer.
Form Flow 99: Cancelled forms are not available in electronic formats. Click on link for a list of
Other: Forms Management POCs.

Forms Management POCs

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REMARKS:
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ISSUANCES: DOD 6010.8-R, CH 6
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SPONSOR / POC: HA SUB-SPONSOR: TRICARE MGMT
NUMBER OF PAGES: 4
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USERS*: A N AF
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PRESCRIBED OR ADOPTED?: P

DISPOSITION: S

FUNCTION CODE: 6010

FORM CONTROLLED: N

MANDATORY PRINT SPECIFICATIONS: N

RCS:

IRCN:

OMB: 0720-0006

PRIVACY ACT IMPLICATIONS: Y
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* All revisions and/or cancellations must be coordinated through these USERS.

DISPOSITION: S = Do NOT use previous edition. U = Use previous edition until supply is depleted.