DD FORM 2642 APR 2007 PREVIOUS EDITION IS OBSOLETE. COPY 1 - PATIENT S COPY Adobe Professional 7. 0 2. If the sponsor and patient are the same enter same. DD FORM 2642 BACK APR 2007 11. By law you must report if the patient is covered by any other health insurance to include health coverage available through other family members. WHERE TO OBTAIN ADDITIONAL FORMS You may obtain additional claim forms from your claims processor the TRICARE Service Center at the nearest military treatment...
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This is a demonstration on how to properly fill out a DD Form 1351 tattoo we will cover each block on the form let us begin block one payment electronic funds transfer will always be checked reason being dispersing no longer issues hard checks if you owe on your government travel charge card for more admin 216 / 13 it is mandatory to input the split is person it for the amount charged blocks 2 through 4 in these blocks print your lasts first and middle initial of your name pay grade and your full social security number block 5 type of payment if this is a deity trip ensure that the TDY and member employee box is checked block 6 address here you will provide your house number and Street along with the city state and zip code this address must match the address on the front page of your orders also provide an email address to be best contacted block 7 day time telephone number for this block and put the best day time telephone number so that you may be reached in case of any questions regarding your claim block 8 travel order / authorization number this can be found on the top right hand side of your orders the standard document number SC n can be located in paragraph 3 of your orders block 9 leave blank this is use for PCs claims only block 10 for dispersing office only this block is used for the dispersing office only however 10 D can be used for extra computations and notes for your travel claim such as leave drills in conjunction back to back orders or to specify a partial claim block 11 organisation in station this will be the parent command that authorized your orders block 12 to Penn check on a company reason being your dependents are only authorized for your travel on PCs orders block 13 leave blank this is used for our PCs claim block 14 have household goods been shipped and sure to click no this portion is also used for PCs claims explanation is also for a pcs clean block 15 itinerary please scan forward to the following subtype demonstrations you block 15 is the itinerary it is considered the most important portion of your 1351 tattoo this must be completed accurately we will go over filling out annual training in active-duty PME and a Doss claims as they all resemble each other within the itinerary block 15 eight this is the date you started your travel block 15 B these are the lives of travel in which you executed this should tell the story of your trip block 15 C and D this is the mode of travel this can be located in the second page of your 1351 tattoo Lock 15e this is where you will input the lodging costs this needs to be annotated next to the TD period in which the cost was occurred block 15fps e miles if you drove your personal auto or if you were dropped off by your spouse and put the mileage in the Block next to the PA period you can also utilize 1351 tech to Charlie for more room if needed for blocks 15 A through F for example we will use the dates from 1 September to 12 September 2014 - Camp Lejeune North Carolina government...