|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 evening telephone numbers 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: 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, Statement of Personal Injury-Possible Third Party Liability.
|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.
If you know the diagnosis code, you can include it. If not, please be descriptive.
|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 name. If the sponsor is the patient, enter "same."
|Box 10: Sponsor's Social Security Number
||Enter the Sponsor's Social Security Number (SSN) or Department of Defense Benefits Number (DBN). Former spouses should use their own SSN. The DBN is the 11-digit number on the back of the ID Card.
|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 about other health insurance.
|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.