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The DD Form 2527 is an essential document for individuals who have suffered personal injuries and are seeking medical care through TRICARE, the health program serving uniformed service members, retirees, and their families. This form is specifically designed to collect crucial information that allows TRICARE to determine potential third-party liability for medical expenses incurred as a result of the injury. Users are required to provide personal details, including the injured patient's name and contact information, as well as a description of the incident, such as traffic accidents, slips and falls, or any other causative events. There are distinct sections to outline the nature of the injury and the responsible parties involved, which is vital for initiating recovery efforts for medical costs. Completing this form accurately and returning it promptly is critical; failure to do so can lead to delays or denials of claims. Additionally, this form operates under the privacy guidelines set forth by the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA), ensuring that the information collected is handled appropriately and only utilized for purposes directly related to the claim. Nonetheless, while the form is a key step in the claims process, it’s crucial for individuals to consult legal counsel regarding any potential legal action following their injuries.

Dd 2527 Example

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY

DEFENSE HEALTH AGENCY

OMB No. 0720-0003 Exp.: 30 Apr 2022

IF A PREADDRESSED ENVELOPE IS NOT ENCLOSED WITH THIS FORM, PLEASE RETURN YOUR COMPLETED FORM TO EITHER OF THESE LOCATIONS:

(1)THE TRICARE PROCESSOR WHO SENT YOU THE FORM; OR

(2)THE TRICARE CLAIMS PROCESSOR FOR THE STATE/COUNTRY IN WHICH YOU RECEIVED THE MEDICAL CARE (the Health Benefits Advisor at your nearest military installation can provide you with this address).

The public reporting burden for this collection of information, 0720-0003, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 C.F.R. 199 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To collect information necessary to determine when third parties may be held liable for medical care resulting from your injuries and to permit TRICARE to seek recovery for the cost of such care from those parties.

ROUTINE USE(S): Use and disclosure of your records outside of DoD may occur in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Collected information may also be shared with entities including the Departments of Health and Human Services, Veterans Affairs, Department of Justice, and other Federal, State, local, or foreign government agencies, or authorized private business entities for matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of TRICARE.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases.

For a full listing of the applicable Routine Uses for this system, refer to the applicable SORN.

APPLICABLE SORN: EDTMA 04, Medical/Dental Claim History Files (October 27, 2015, 80 FR 65720 https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/

DISCLOSURE: Voluntary. However, failure to provide information may result in a delay processing your claim(s) and/or the denial of your claim(s).

INSTRUCTIONS

We recently received a 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.

Payment of your claims has been suspended until we receive more information. Your claims, and any related claims that are subsequently received, will be denied if this form is not completed and returned within 35 days from the date of this letter.

This information is requested solely for the purpose of processing your TRICARE claim. It has no bearing on any legal action you may pursue as a result of your injury. All questions you may have concerning possible legal actions should be referred to an attorney. Do not execute a release or settle any personal injury claim you may have without notice to a military claims officer.

DD FORM 2527, MAR 2020

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 2

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY

DEFENSE HEALTH AGENCY

Please fill out this form to permit the United States to recover medical expenses from whoever caused your injury. Processing of your TRICARE claim will be suspended until you complete and return this form in the attached self-addressed envelope. Address questions to any

Judge Advocate office or call toll free telephone number

1-800-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I - GENERAL INFORMATION

 

 

 

 

 

 

 

1. SPONSOR'S SOCIAL SECURITY NUMBER:

 

ARMY

 

 

 

NAVY

AIR FORCE

 

 

COAST GUARD

USPHS

NOAA

2. A. INJURED PATIENT'S NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. INJURED PATIENT'S ADDRESS:

 

 

 

 

 

 

C. TELEPHONE

 

 

 

 

 

 

 

 

3. DATE INJURY OCCURED (YYYYMMDD)

 

 

 

 

 

APPROXIMATE TIME OF INJURY:

 

 

 

 

 

 

 

 

4. LOCALITY AND STATE WHERE INJURY OCCURRED:

 

 

 

 

 

 

 

SECTION II - TYPE AND CAUSE OF INJURY

5.TRAFFIC ACCIDENT. (Give name of at-fault driver and insurance company name. If you were a passenger in the accident vehicle, give name of driver and driver's insurance company.)

6.SLIP/FALL, DOG BITE, MISHAP. (Give name of employer, business, municipality, or homeowner where injury occurred.)

7.EXPLOSION. (Specify type of explosive, name and address of place where injury occurred.)

8.ASSAULT. (Give name(s) of person(s) who assaulted you, and responding police department.)

9.TOXIC SUBSTANCE. (Specify substance or drug name, and place where the incident occurred.)

10.ON-THE-JOB INJURY. (Give name and address of employer, and cause of injury.)

11.PRODUCT MALFUNCTION. (Give product name and place where the injury occurred.)

12.MEDICAL MALPRACTICE. (Give date you first knew of the malpractice, doctor's name, and place where the malpractice occurred.)

13.OTHER TYPE AND CAUSE OF INJURY. (Specify.)

SECTION III - MISCELLANEOUS

14. LIST OF MILITARY MEDICAL FACILITIES THAT PROVIDED CARE FOR THIS INJURY, AND DATES OF TREATMENT:

15. HAVE YOU HIRED A LAWYER TO REPRESENT YOU REGARDING THIS INJURY?

YES

NO

 

 

A. LAWYER'S NAME AND ADDRESS:

B. LAWYERS TELEPHONE NUMBER:

 

 

 

16. DO YOU HAVE INSURANCE?

YES

NO

 

 

A. NAME OF INSURANCE PROVIDER(S):

B. INSURANCE TELEPHONE NUMBER(S):

 

 

 

17. YOUR SIGNATURE

 

18. DATE SIGNED (YYYYMMDD)

DD FORM 2527, MAR 2020

Page 2 of 2

 

PREVIOUS EDITION IS OBSOLETE.
Get Dd 2527 PDF Form

Form Characteristics

Fact Name Details
Form Purpose The DD Form 2527 is used to collect information necessary for determining third-party liability regarding medical expenses related to personal injuries.
Privacy Act Compliance This form operates under the Privacy Act of 1974, which protects the disclosure of personal information gathered during the claims process.
Completion Deadline The completed form must be returned within 35 days of receiving it to avoid denial of the claim.
OMB Approval The form has been assigned an OMB control number (0720-0003) indicating its approval for use.
Use of Information Information provided may be shared with government agencies for various purposes including claims processing and fraud investigations.
Legal Notice Individuals are advised not to execute a release or settle claims without notifying a military claims officer.
Governing Laws The DD Form 2527 is governed by 10 U.S.C. Chapter 55 regarding Military Medical Care and 32 C.F.R. 199 concerning the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
Voluntary Disclosure Providing information on the form is voluntary, but failure to do so may lead to delays or denials in processing claims.
Collection Burden The estimated average time to complete the form is approximately 15 minutes, including the time to collect necessary data.
Form Version The current version of the DD Form 2527 was issued in March 2020, and previous editions are now obsolete.

Guidelines on Utilizing Dd 2527

Completing the DD Form 2527 is a critical step in ensuring that your medical claims related to an injury are processed correctly. This form collects vital information that allows for the determination of third-party liability and facilitates recovery of costs associated with your medical care. Here is a step-by-step guide on how to fill out the form accurately.

  1. Section I - General Information:
    • 1. Sponsor's Social Security Number: Enter the last four digits of the Social Security number of the sponsor.
    • 2. Injured Patient's Information:
      • A. Write the name of the injured patient.
      • B. Provide the injured patient’s current address.
      • C. Include a telephone number where the patient can be reached.
    • 3. Date and Time of Injury: Indicate the date of the injury in YYYYMMDD format and the approximate time it occurred.
    • 4. Location of Injury: Describe the locality and state where the injury took place.
  2. Section II - Type and Cause of Injury:
    • 5. Traffic Accident: Provide the name of the at-fault driver and their insurance company.
    • 6. Slip/Fall, Dog Bite, Mishap: Mention the name of the employer, business, municipality, or homeowner related to the injury.
    • 7. Explosion: Specify the type of explosive and the place where the injury occurred.
    • 8. Assault: List the names of individuals who assaulted you and the responding police department.
    • 9. Toxic Substance: Identify the substance or drug name and the place of the incident.
    • 10. On-the-Job Injury: Include the name and address of the employer along with the cause of the injury.
    • 11. Product Malfunction: State the product name and where the injury occurred.
    • 12. Medical Malpractice: Give the date you first became aware of the malpractice, the doctor's name, and the location of the incident.
    • 13. Other Type and Cause of Injury: Specify any other injuries that are not listed.
  3. Section III - Miscellaneous:
    • 14. List of Military Medical Facilities: Indicate the military facilities where you received care for the injury along with the dates of treatment.
    • 15. Lawyer Representation: Answer whether you have hired a lawyer regarding the injury and, if so, provide their name, address, and telephone number.
    • 16. Insurance Information: Indicate if you have insurance, and if yes, name the provider and provide their contact number.
    • 17. Signature: Sign the form to verify the information is accurate.
    • 18. Date Signed: Include the date you signed the form in YYYYMMDD format.

Once you have completed the DD Form 2527, review your information for accuracy before submitting it. Sending the completed form to the appropriate TRICARE claims processor will help to ensure that your claims can be processed without unnecessary delays.

What You Should Know About This Form

What is the purpose of the DD Form 2527?

The DD Form 2527, also known as the Statement of Personal Injury - Possible Third Party Liability, is primarily used by the United States Department of Defense (DoD) to gather information regarding potential third-party liability for medical expenses related to personal injuries. When an individual receives medical care due to an injury that may involve another party's responsibility, this form allows TRICARE, the health care program for uniformed service members, to pursue recovery of costs from the responsible party.

Who should fill out the DD Form 2527?

The form should be filled out by the injured individual or their appointed representative. This may include a family member or legal representative, especially if the injured party is unable to complete the form themselves. Accurate and thorough completion of the form is essential, as it directly impacts the processing of the related TRICARE claims.

What happens if I do not return the DD Form 2527 on time?

If the completed DD Form 2527 is not returned within 35 days of the request, payment for the related medical claims will be denied. Timely submission is crucial to avoid delays or denials that could affect the coverage of medical expenses associated with the injury.

How does the information collected through the DD Form 2527 get used?

The information provided on the DD Form 2527 is utilized to assess potential third-party liability and to facilitate reimbursement from those parties for medical care costs incurred due to the injury. This data may be shared within various federal and state agencies as allowed by the Privacy Act and other relevant regulations to ensure effective claims processing and program integrity.

Do I need to hire an attorney to complete the DD Form 2527?

No, hiring an attorney is not a requirement for completing the form. However, individuals who have legal claims or are involved in litigation related to their injuries may benefit from legal representation to navigate those issues effectively. It is advisable to consult with a legal professional if there are questions about personal injury claims or the implications of the information provided in the form.

What should I do if I have questions while filling out the DD Form 2527?

If questions arise while completing the DD Form 2527, individuals can seek assistance from any Judge Advocate office or contact the toll-free number provided in the form. These resources can provide necessary guidance to ensure accurate completion and submission of the form.

Common mistakes

When filling out the DD Form 2527, many common mistakes can lead to delays in processing your claim. One frequent error involves omitting key details. Be sure to provide complete information about the injured patient, including their name, address, and contact number. Missing any of these pieces can result in your form being returned for additional information.

Another mistake is failing to adhere to deadlines. The form must be submitted within 35 days of receiving the notice about your claim. If you miss this deadline, your claim may be denied. It’s crucial to mark your calendar and prioritize completing the form to avoid unnecessary delays.

Some individuals also neglect to provide information regarding prior medical treatment. Be thorough when listing military medical facilities that provided care for the injury, including the dates of treatment. This information is vital for processing your claim accurately and efficiently.

In section II, misidentifying the type and cause of the injury is another common error. Accurately describing how the injury occurred is essential. If you were involved in a traffic accident, provide specific information about the at-fault party, including their insurance details. Leaving this information vague can create complications.

Additionally, not indicating whether you have hired a lawyer can lead to confusion. If you have represented yourself legally, it’s important to provide your lawyer's information. This helps streamline the communication process with all parties involved in your claim.

Many people forget to sign and date the form before submission. A missing signature is an easy-to-make mistake that can delay the processing of your claim. Always double-check to ensure that your signature and the date are included at the bottom of the form.

Lastly, not using the provided envelope for returning the form can cause misdirected mail. Make sure to use the pre-addressed envelope or return the form to the correct address provided in the instructions. Using the incorrect address can result in further delays to your claim.

Documents used along the form

The DD Form 2527, known as the Statement of Personal Injury, is a key document for those seeking medical claims through the TRICARE health program. When completing this form, you may encounter other important documents that are frequently used alongside it. Each serves a specific purpose in the claims process, ensuring that your claim is assessed accurately and efficiently. Let’s explore these commonly used forms and documents.

  • DD Form 214: This is the Certificate of Release or Discharge from Active Duty. It provides evidence of military service and is often required for members filing claims related to their service.
  • DD Form 149: This form allows veterans to apply for a correction of their military records. It may be necessary if there are discrepancies regarding the nature of an injury or service-related issues.
  • SF 180: The Request Pertaining to Military Records form is used to request copies of military service records. These records can be crucial in establishing your eligibility for certain benefits.
  • TRICARE Claim Form (DD Form 2642): This form is used to file a claim for medical expenses. It includes details of medical treatment and is essential for processing your claim with TRICARE.
  • Letter from a Health Care Provider: A letter detailing the treatment received, medical condition, or necessary follow-up can strengthen your claim. This documentation supports the information provided in the DD Form 2527.
  • Witness Statements: If applicable, statements from witnesses regarding the accident can help corroborate your account. Such documents can be critical in establishing third-party liability.
  • Police Reports: Official reports from law enforcement can provide vital details about the incident that led to your injury. They can serve as official evidence indicating fault or liability.
  • Insurance Policy Documentation: Copies of insurance policies may be required to determine coverage and liability. These documents clarify any benefits or payments related to the injury.
  • Settlement Agreement (if applicable): If you’ve reached a settlement with a third party, documentation of this agreement will be necessary. It helps TRICARE determine if recovery for medical costs is appropriate.
  • Health Insurance Claims: Claims submitted to your private insurer may need to be included as they can provide insight into the medical expenses incurred and the coverage that applies.

Collecting these documents can seem daunting, but each one plays a crucial role in ensuring that your claim is processed effectively. By understanding their purpose and keeping them organized, you can navigate the claims process more smoothly and address any potential issues that arise along the way.

Similar forms

  • DD Form 2540: This form is a Statement of Personal Injury for VA benefits. Like the DD Form 2527, it collects information about the injury and possible third-party liability to facilitate claims processing.
  • VA Form 21-526EZ: This document is used for Veterans to apply for disability compensation or pension. Similar to the DD Form 2527, it requires detailing personal injury information and understanding potential liability.
  • SF 95 (Claim for Damage, Injury, or Death): This form allows individuals to file tort claims against the U.S. government. It parallels the DD Form 2527 as it seeks information concerning injuries and the circumstances surrounding them.
  • Form 10-10EZ: This is an application for health benefits from the Department of Veterans Affairs. It shares similarities with the DD Form 2527 in that it requests details regarding medical treatment related to injuries.
  • CMS-1500: This is a standard claim form for medical reimbursement. Both this form and the DD Form 2527 are necessary to process claims for medical care, focusing on injury details.
  • TRICARE Claim Form (DD Form 2642): Used for submitting claims for TRICARE benefits, this form is akin to the DD Form 2527 because it gathers information related to the individual's medical care and possible liability.
  • Medicare Claim Form (CMS-1490S): This is used to claim services covered by Medicare. Like the DD Form 2527, it seeks specific injury-related information to process healthcare claims.
  • Form 21-4142: This form allows claimants to authorize the release of medical records to support benefits claims. It is similar to the DD Form 2527, as both focus on injuries and care documentation.
  • Form N-400 (Application for Naturalization): This form requires information about arrests and legal issues that could impact eligibility for citizenship. It is similar in its collection of personal information related to incidents affecting the applicant.
  • State Workers' Compensation Forms: These forms vary by state but generally collect details on workplace injuries. Like the DD Form 2527, they assess injury circumstances to determine liability and care options.

Dos and Don'ts

When filling out the DD 2527 form, there are several important things to keep in mind. Here’s a list of what to do and what to avoid:

  • Do read all instructions carefully before starting the form.
  • Do provide accurate and complete information to avoid delays.
  • Do use the self-addressed envelope to return the completed form.
  • Do sign and date the form before submission.
  • Do reach out to a Judge Advocate office if you have questions.
  • Don’t skip any sections, especially those related to the cause of the injury.
  • Don’t submit your form to the Department of Defense.
  • Don’t seal any legal agreements regarding your injury before consulting with a military claims officer.
  • Don’t take too long — return the form within 35 days to avoid claim denial.

Misconceptions

Misunderstandings about the DD 2527 form can lead to confusion for individuals navigating personal injury claims. Here are six common misconceptions clarified:

  • The DD 2527 form is solely for legal proceedings. Many people believe that this form is only relevant if they intend to pursue a lawsuit. In reality, the DD 2527 is primarily used to gather information regarding potential third-party liability for medical care costs, not to initiate legal action.
  • Completing the DD 2527 form guarantees claim approval. Some may think that submitting this form will automatically result in the approval of their claim. While it is a necessary step in the claim process, it does not ensure that the claim will be accepted or that costs will be covered.
  • One can skip filling out the DD 2527 if there is no known third party. A common error is assuming that the form is irrelevant if the incident did not involve another party. However, it is essential to complete the form to allow the TRICARE system to evaluate the situation fully, regardless of perceived third-party involvement.
  • Submitting the DD 2527 is optional. Some individuals may think that completing this form is merely a suggestion. In fact, failing to submit the DD 2527 can lead to delayed processing or even denial of the claim. Timely completion and submission are crucial.
  • The information on the DD 2527 is confidential and will not be shared. While it is true that patient data is somewhat protected, individuals often underestimate how this information can be shared with other entities, including governmental organizations. Awareness of potential data sharing is important for those concerned with privacy.
  • You cannot consult with an attorney if you submit the DD 2527. Some may think that filling out this form limits their ability to seek legal help. This is a misconception. Individuals are encouraged to consult a legal professional regarding any personal injury claim, even after submitting the DD 2527.

Understanding these misconceptions can help individuals navigate the complexities of their claims with greater confidence and clarity.

Key takeaways

Here are some key takeaways regarding the DD 2527 form:

  • Purpose: This form is essential for determining third-party liability related to medical injuries.
  • Timeliness: Ensure you return the completed form within 35 days to avoid claim denials.
  • Information Required: Fill in personal details, specifics about the injury, and any involved parties.
  • Legal Guidance: Consult an attorney for legal action, but do not settle any claims without military claims officer notification.
  • Claim Processing: Processing of your TRICARE claim will be suspended until the form is completed and returned.
  • Privacy Compliance: The information will be protected under the Privacy Act but may be shared with relevant authorities.
  • Voluntary Disclosure: While providing information is voluntary, lack of information can delay or deny claims.
  • Support Contacts: For questions, reach out to a Judge Advocate office or call the provided toll-free number.

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