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Third- party liability. tricare dod/ champus claim form- patient' s request for medical payment dd form 2527 pdf ( dd form 2642) in most cases your provider will file the claim and you' ll get an explanation of benefits showing what was paid. sometimes, you' ll need to file your own claims ( i. the federal medical recovery act allows tricare dd form 2527 pdf to be reimbursed for its costs of treating you if you are injured in an accident that was caused by someone else. instructions we recently received a pdf 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. statement of personal injury- possible third party liability ( dd form 2527) use this form to explain if your care is due to an accident caused by someone else. your regional contractor will send you the statement of personal injury- possible third party liability ( dd form 2527) if a claim is received that appears to have. third party liability occurs when someone else ( an individual, organization, or business) may have been responsible for your injury or illness. if accident or work related, the patient is required to complete dd form 2527, statement of personal injury- possible third party liability.
check box to indicate if patient' s condition is accident related, work related or both. when traveling or getting care from a non- participating provider). box 8a: describe condition for which patient received treatment, supplies, or medication payment of your claims has been suspended pdf until we receive more information.
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