unstructuredio/SCORE-Bench · Datasets at Hugging Face

text stringlengths 0 2.18k
7. IS PATIENT'S CONDITION (X both if applicable)
If yes, see #7 in section below
ACCIDENT RELATED? [] Yes [] No
WORK RELATED? [] Yes [] No

8a. DESCRIBE ILLNESS, INJURY OR SYMPTOMS THAT REQUIRED TREATMENT, SUPPLIES OR REASON FOR MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED (Do not list services performed). REFER TO INSTRUCTIONS BELOW.
8b. WAS PATIENT'S CARE (X one)
[] INPATIENT? [] OUTPATIENT? [] DAY SURGERY? [] PHARMACY?
8c. OVERSEAS CLAIMS ONLY
[] TELEMEDICINE? [] URGENT CARE? [] TELEMEDICINE/ AUDIO: reason for audio only:

9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle Initial)

10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY NUMBER OR DOD BENEFITS NUMBER (DBN)

11. OTHER HEALTH INSURANCE COVERAGE
a. Is patient covered by any other health insurance plan or program to include travel insurance or health coverage available through other family members? For patients overseas this includes National Health Insurance. If yes, check the "Yes" block and complete blocks 11 and 12 (see instructions below). If no, you must check the "No" block and complete block 12. Do not provide TRICARE/CHAMPUS supplemental insurance information, but do report Medicare supplements. [] YES [] NO

b. TYPE OF COVERAGE (Check all that apply)
[] (1) EMPLOYMENT (Group) [] (3) MEDICARE [] (5) MEDICARE SUPPLEMENTAL INSURANCE [] (2) PRIVATE (Non-Group) [] (4) STUDENT PLAN [] (6) PRESCRIPTION PLAN [] (7) OTHER (Specify)

c. OVERSEAS CLAIMS ONLY (Check all that apply)
[] (1) TRAVEL INSURANCE [] (2) MEDICARE ADVANTAGE [] (3) VA FOREIGN MEDICAL PROGRAM

d. NAME AND ADDRESS OF OTHER HEALTH INSURANCE (Street, City, State, and ZIP Code)

e. INSURANCE IDENTIFICATION NUMBER

f. INSURANCE EFFECTIVE DATE (YYYYMMDD)

g. DRUG COVERAGE?
INSURANCE 1 [] YES [] NO
INSURANCE 2 [] YES [] NO

REMINDER: Attach your other health insurances's Explanation of Benefits or pharmacy receipt that indicates the actual drug cost, amount the OHI paid, and the amount that you paid.

12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.

a. SIGNATURE (Common Access Card or Physical signature required)

b. DATE SIGNED (YYYYMMDD)

c. RELATIONSHIP TO PATIENT

13. OVERSEAS CLAIMS ONLY:
PAYMENT IN US OR FOREIGN CURRENCY? [] US Dollar [] Local Foreign
PROOF OF PAYMENT:
Did you make payment to provider?
REMINDER: Attach proof of payment [] YES [] NO

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HOW TO FILL OUT THE TRICARE/CHAMPUS FORM
--------------------------------------------------- Unstructured Sub-Title End
You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.

1. Enter patient's last name, first name and middle initial as it appears on the military ID Card. Do not use nicknames.

2. Enter the patient’s primary telephone number and secondary telephone number to include the area code and/or country code.

3a. Enter the complete address of the patient's place of residence at the time of service (street number, street name, apartment number, city, state/country, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and numbers.

3b. Identify the State/Country of where the services were rendered.

4. Check the box to indicate patient's relationship to sponsor. If "Other" is checked, indicate how related to the sponsor; e.g., parent.

5. Enter patient's date of birth (YYYYMMDD).

6. Check the box for either male or female (patient).

7. 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 TRICARE Management Activity." Download the form at https:// tricare.mil/forms.

8a. 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. Include health reason for prescription needs (e.g. diabetic, hypothyroid).

8b. Check the box to indicate where the care was given.

8c. If this claim is for care received overseas, indicate if services were received by telemedicine.

9. Enter the Sponsor's or Former Spouse's last name, first name and middle initial as it appears on the military ID Card. If the sponsor and patient are the same, enter "same."

10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN) or Patient's DoD Benefits Number (DBN). Note: the sponsor number may be your own SSN.

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. If the patient has supplemental TRICARE/ CHAMPUS insurance, do not report. You must, however, report Medicare supplemental coverage. Block 11 allows space to report two insurance coverages. If there are additional insurances, report the information as required by Block 11 on a separate sheet of paper and attach to the claim. Pharmacy specific plans must be reported. NOTE: All other health insurances except Medicaid and TRICARE/ CHAMPUS supplemental plans must pay before TRICARE/CHAMPUS will pay. With the exception of Medicaid and CHAMPUS supplemental plans, you must first submit the claim to the other health insurer and after that insurance has determined their payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to this claim. If care is provided overseas you must include EOBs for any portion a travel insurance or Medicare Advantage Plan reimbursed. If VA Foreign Medical Program (FMP) reimbursed a portion of services you must include a copy of the FMP EOB. The claims processor cannot process claims until you provide the other health insurance information.

12. 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 Block 12a. and sign the claim. Physical wet signature or Common Access Card (CAC) is required.
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.

13. If this is a claim for care received overseas, indicate if you want payment in US or local foreign currency. Check the box if you made payment to the provider and ensure proof of payment is attached to claim.
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DD FORM 2642, SEP 2024
PREVIOUS EDITION IS OBSOLETE.
CUI (when filled in)
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Page 2 of 2
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7. IS PATIENT'S CONDITION (X both if applicable)

If yes, see #7 in section below

ACCIDENT RELATED? [] Yes [] No

WORK RELATED? [] Yes [] No

8a. DESCRIBE ILLNESS, INJURY OR SYMPTOMS THAT REQUIRED TREATMENT, SUPPLIES OR REASON FOR MEDICATION. IF AN INJURY, NOTE HOW IT HAPPENED (Do not list services performed). REFER TO INSTRUCTIONS BELOW.

8b. WAS PATIENT'S CARE (X one)

[] INPATIENT? [] OUTPATIENT? [] DAY SURGERY? [] PHARMACY?

8c. OVERSEAS CLAIMS ONLY

[] TELEMEDICINE? [] URGENT CARE? [] TELEMEDICINE/ AUDIO: reason for audio only:

9. SPONSOR'S OR FORMER SPOUSE'S NAME (Last, First, Middle Initial)

10. SPONSOR'S OR FORMER SPOUSE'S SOCIAL SECURITY NUMBER OR DOD BENEFITS NUMBER (DBN)

11. OTHER HEALTH INSURANCE COVERAGE

a. Is patient covered by any other health insurance plan or program to include travel insurance or health coverage available through other family members? For patients overseas this includes National Health Insurance. If yes, check the "Yes" block and complete blocks 11 and 12 (see instructions below). If no, you must check the "No" block and complete block 12. Do not provide TRICARE/CHAMPUS supplemental insurance information, but do report Medicare supplements. [] YES [] NO

b. TYPE OF COVERAGE (Check all that apply)

[] (1) EMPLOYMENT (Group) [] (3) MEDICARE [] (5) MEDICARE SUPPLEMENTAL INSURANCE [] (2) PRIVATE (Non-Group) [] (4) STUDENT PLAN [] (6) PRESCRIPTION PLAN [] (7) OTHER (Specify)

c. OVERSEAS CLAIMS ONLY (Check all that apply)

[] (1) TRAVEL INSURANCE [] (2) MEDICARE ADVANTAGE [] (3) VA FOREIGN MEDICAL PROGRAM

d. NAME AND ADDRESS OF OTHER HEALTH INSURANCE (Street, City, State, and ZIP Code)

e. INSURANCE IDENTIFICATION NUMBER

f. INSURANCE EFFECTIVE DATE (YYYYMMDD)

g. DRUG COVERAGE?

INSURANCE 1 [] YES [] NO

INSURANCE 2 [] YES [] NO

REMINDER: Attach your other health insurances's Explanation of Benefits or pharmacy receipt that indicates the actual drug cost, amount the OHI paid, and the amount that you paid.

12. SIGNATURE OF PATIENT OR AUTHORIZED PERSON CERTIFIES CORRECTNESS OF CLAIM AND AUTHORIZES RELEASE OF MEDICAL OR OTHER INSURANCE INFORMATION.

a. SIGNATURE (Common Access Card or Physical signature required)

b. DATE SIGNED (YYYYMMDD)

c. RELATIONSHIP TO PATIENT

13. OVERSEAS CLAIMS ONLY:

PAYMENT IN US OR FOREIGN CURRENCY? [] US Dollar [] Local Foreign

PROOF OF PAYMENT:

Did you make payment to provider?

REMINDER: Attach proof of payment [] YES [] NO

--------------------------------------------------- Unstructured Sub-Title Begin

HOW TO FILL OUT THE TRICARE/CHAMPUS FORM

--------------------------------------------------- Unstructured Sub-Title End

You must attach an itemized bill (see front of form) from your doctor/supplier for CHAMPUS to process this claim.

1. Enter patient's last name, first name and middle initial as it appears on the military ID Card. Do not use nicknames.

2. Enter the patient’s primary telephone number and secondary telephone number to include the area code and/or country code.

3a. Enter the complete address of the patient's place of residence at the time of service (street number, street name, apartment number, city, state/country, ZIP Code).

Do not use a Post Office Box Number except for Rural Routes and numbers.

3b. Identify the State/Country of where the services were rendered.

4. Check the box to indicate patient's relationship to sponsor. If "Other" is checked, indicate how related to the sponsor; e.g., parent.

5. Enter patient's date of birth (YYYYMMDD).

6. Check the box for either male or female (patient).

7. 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 TRICARE Management Activity." Download the form at https:// tricare.mil/forms.

8a. 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. Include health reason for prescription needs (e.g. diabetic, hypothyroid).

8b. Check the box to indicate where the care was given.

8c. If this claim is for care received overseas, indicate if services were received by telemedicine.

9. Enter the Sponsor's or Former Spouse's last name, first name and middle initial as it appears on the military ID Card. If the sponsor and patient are the same, enter "same."

10. Enter the Sponsor's or Former Spouse's Social Security Number (SSN) or Patient's DoD Benefits Number (DBN). Note: the sponsor number may be your own SSN.

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. If the patient has supplemental TRICARE/ CHAMPUS insurance, do not report. You must, however, report Medicare supplemental coverage. Block 11 allows space to report two insurance coverages. If there are additional insurances, report the information as required by Block 11 on a separate sheet of paper and attach to the claim. Pharmacy specific plans must be reported. NOTE: All other health insurances except Medicaid and TRICARE/ CHAMPUS supplemental plans must pay before TRICARE/CHAMPUS will pay. With the exception of Medicaid and CHAMPUS supplemental plans, you must first submit the claim to the other health insurer and after that insurance has determined their payment, attach the other insurance Explanation of Benefits (EOB) or work sheet to this claim. If care is provided overseas you must include EOBs for any portion a travel insurance or Medicare Advantage Plan reimbursed. If VA Foreign Medical Program (FMP) reimbursed a portion of services you must include a copy of the FMP EOB. The claims processor cannot process claims until you provide the other health insurance information.

12. 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 Block 12a. and sign the claim. Physical wet signature or Common Access Card (CAC) is required.

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.

13. If this is a claim for care received overseas, indicate if you want payment in US or local foreign currency. Check the box if you made payment to the provider and ensure proof of payment is attached to claim.

--------------------------------------------------- Unstructured Form End

--------------------------------------------------- Unstructured Page Footer Begin

DD FORM 2642, SEP 2024

PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

--------------------------------------------------- Unstructured Page Number Block Begin

Page 2 of 2

--------------------------------------------------- Unstructured Page Number Block End

--------------------------------------------------- Unstructured Page Footer End

--------------------------------------------------- Unstructured Plain Text Format 1.0.4

--------------------------------------------------- Unstructured Image Begin