Tricare Third Party Libility Insurance Form

Tricare east region attn.

Tricare third party libility insurance form. If accident or work related the patient is required to complete dd form 2527 statement of personal injury possible third party liability. 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. For all tricare dental program forms click here. For all active duty dental program forms click here.

Third party liability p o. 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 involvement. Box 8968 madison wi 53707 8968 fax. Claims submitted with diagnosis codes 800 999 for professional services exceeding 500 and inpatient services often indicate an accidental injury or illness.

When filing these claims the provider needs to have the beneficiary complete the possible third party liability form. The grievance may be against any member of your health care team. Third party liability claim form. Request authorization for disclosure of health information.

This includes your tricare doctor your contractor or a subcontractor. Sometimes tricare receives claims that include diagnosis codes that may or may not relate to an injury. Describe condition for which patient received treatment supplies or medication. Public facility use certification form.