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The DD Form 2527, also known as the Statement of Personal Injury, plays a crucial role for individuals seeking medical reimbursement through the TRICARE program after sustaining an injury possibly linked to a third party's actions. This form is required when a claim has been filed for medical services related to such injuries, and it addresses the essential details needed to assess third-party liability. The completion and submission of the DD 2527 enable TRICARE to pursue recovery of medical expenses from the party responsible for the injury. It is important to note that submitting this form is not just a bureaucratic obligation; it directly influences the processing of claims, which may be temporarily suspended until the form is received. The form requires information about the injured party, the circumstances surrounding the injury, and any involved parties, including insurance details. Additionally, while the expectation to provide accurate information is mandatory, individuals should be aware of their privacy rights, as the form includes provisions related to the handling and disclosure of protected health information. Ultimately, understanding the significance of the DD Form 2527 can help individuals navigate the complexities of both their medical claims and any potential legal actions associated with 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 [email protected]. 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.

File Breakdown

Fact Name Fact Description
Purpose The DD 2527 form is used to collect information regarding possible third-party liability for medical care related to personal injuries.
Submission Guidelines Completed forms should be returned to the TRICARE processor that provided the form, or to the TRICARE Claims Processor for the state where care was received.
Legal Authority The form is governed by 10 U.S.C. Chapter 55 and 32 C.F.R. 199.
Privacy Compliance Information collected may be shared as permitted by the Privacy Act of 1974 and HIPAA rules, ensuring confidentiality of personal health information.
Response Timeframe Individuals must complete and submit the form within 35 days to avoid denial of their claims.

Guide to Using Dd 2527

After filling out the DD Form 2527, you will need to submit it to the appropriate TRICARE claims processor. Your completed form must be sent in a timely manner to avoid any delays or denials in processing your claim. Ensure you provide accurate information, as this will help expedite the process.

  1. Begin by writing the sponsor's Social Security Number in the designated field.
  2. In Section I, provide the injured patient's name and address. Be sure to include a contact telephone number as well.
  3. Record the date of the injury, in the format YYYYMMDD, along with the approximate time of the incident.
  4. Specify the locality and state where the injury occurred.

Next, move to Section II to describe the type and cause of the injury. Provide details as follows:

  • If the injury was caused by a traffic accident, indicate the at-fault driver’s name and their insurance company. If you were a passenger, provide the driver’s information.
  • For slip and fall incidents or dog bites, mention the name of the employer, business, municipality, or homeowner where the event took place.
  • In case of an explosion, specify the type of explosive and the location of the incident.
  • For assaults, list the names of the assailants and the police department that responded.
  • In the case of toxic substances, provide the name of the substance or drug along with the location of the incident.
  • If the injury occurred on the job, capture the employer's name, address, and the cause of the injury.
  • For a product malfunction, state the name of the product and where the injury occurred.
  • In instances of medical malpractice, provide the date you first became aware of the malpractice, the doctor’s name, and the location of the incident.
  • If your case involves another type of injury, please specify.
  1. In Section III, list any military medical facilities that provided care for the injury along with the dates of treatment.
  2. Indicate whether you have hired a lawyer to represent you regarding this injury. If so, provide the lawyer's name, address, and telephone number.
  3. State whether you have insurance related to the injury. If yes, include the name of the provider and their contact telephone numbers.
  4. Finally, ensure you sign the form and date it using the format YYYYMMDD.

Be diligent in reviewing your entries to confirm that all information is accurate before wrapping it up and sending it off. This ensures a smoother process in handling your TRICARE claim.

Get Answers on Dd 2527

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 used to gather information about injuries that may involve third-party liability. Its primary purpose is to help the Department of Defense recover medical expenses incurred due to injuries caused by someone else. This process is particularly important for beneficiaries of TRICARE, as their claims may be suspended until the form is completed and returned.

How do I submit the DD Form 2527?

Once you have completed the DD Form 2527, you should return it to either the TRICARE processor that sent you the form or to the TRICARE claims processor in your state or country where you received medical care. If there is a preaddressed envelope included, simply use that. If not, the Health Benefits Advisor at your nearest military installation can assist you in finding the correct address.

What happens if I don't return the form within 35 days?

If you fail to return the DD Form 2527 within 35 days from the date of the notification letter, your claims may be denied. This includes not only the current claim but also any related claims that may arise in the future. It is crucial to adhere to the deadline to ensure the proper processing of your claims.

What information do I need to provide on the form?

The form requires a variety of details, including:

  • The sponsor's Social Security number.
  • The injured patient's name and contact details.
  • The date, time, and location of the injury.
  • Details regarding the type and cause of the injury, such as a traffic accident, slip and fall, or medical malpractice.
  • Information about any military medical facilities where care was received.
  • Whether you have hired an attorney for legal representation related to this injury.
  • Details about any insurance you may have.

How does providing this information impact my claim?

Providing accurate and complete information on the DD Form 2527 is vital for processing your TRICARE claim effectively. If any information is missing or incomplete, it could lead to delays in processing or even denial of your claim. It's essential to take this seriously to ensure timely support for your medical needs.

Is it mandatory to hire a lawyer for this process?

Hiring a lawyer is not a requirement for completing the DD Form 2527 or for the claims process. However, if you have questions about legal actions related to your injury, consulting with an attorney may be beneficial. If you do choose to hire a lawyer, you are encouraged to inform the military claims officer to avoid complications.

What are the privacy considerations with this form?

The personal information you provide on the DD Form 2527 is protected under privacy laws, including the Privacy Act of 1974 and HIPAA. The information will only be used for the purposes stated, such as determining third-party liability and processing TRICARE claims. However, failure to provide the information could hinder your claims process, so weigh your concerns carefully.

Common mistakes

Filling out the DD 2527 form can be a daunting task, and many people unintentionally make mistakes that delay their claims. One common error is failing to provide complete personal information. Make sure to include all necessary details, such as the sponsor's Social Security number and the injured patient's name and address. Omitting any of this information can lead to unnecessary delays in processing.

Another frequent mistake is not clearly indicating the type and cause of the injury. It is important to provide specific details about the incident, such as the names of other involved parties and relevant insurance information. This clarity helps ensure that TRICARE can swiftly pursue recovery from liable third parties.

Many people also neglect to list all medical facilities that treated them for the injury. It’s critical to include all places of care along with the treatment dates. If this information is missing, TRICARE might find it challenging to verify medical services, thus hindering the approval process.

People often overlook the necessity of answering questions about having hired a lawyer. A simple 'yes' or 'no' is not enough; provide the lawyer's name and contact information if applicable. This helps TRICARE understand the legal context of your claim.

Another oversight occurs with the date of the injury. Providing an incorrect date can create confusion when TRICARE tries to match it with other claims or medical records. Always double-check that the date is accurate and in the correct format.

In addition, many form fillers fail to review the privacy notice section carefully. While the collection of information seems lengthy, it is essential to understand how your data is used. Being informed can help you feel more comfortable completing the form.

Lastly, a significant mistake is not returning the form promptly. Remember, you must submit the completed form within 35 days. Delays beyond this deadline could result in denial of your claim. So, take the time to fill it out carefully and send it back as soon as possible to avoid setbacks.

By being mindful of these common mistakes, you enhance your chances of a smooth claim process. Clear communication and attention to detail on your part can make all the difference when navigating this important form.

Documents used along the form

The DD Form 2527, titled "Statement of Personal Injury - Possible Third Party Liability," is typically used in conjunction with several other forms and documents to facilitate the processing of claims related to personal injuries. Below is a list of common forms often associated with the DD Form 2527, along with brief descriptions of each.

  • DD Form 214: This form provides proof of military service and is often required when applying for benefits or during the claims process.
  • DD Form 149: This form is used to apply for an upgrade of discharge status, which may be necessary in certain benefit claims.
  • SF 180: This form is used to request military records and may be needed to accompany claims that relate to past military service.
  • TRICARE Claim Form (DD Form 2642): This form is used to file a claim for reimbursement of healthcare expenses not directly billed to TRICARE.
  • Incident Report: This document details the particulars of the accident or injury, which can support the claim being filed.
  • Medical Authorization Form: This form allows healthcare providers to release patient medical records necessary for processing a claim.
  • Insurance Claim Documentation: This includes the initial claim submission to an insurance company and relevant correspondence that supports the injury claim.
  • Employers Report of Injury: This form documents injuries that occur in the workplace and is often required for workers’ compensation claims.
  • Legal Representation Agreement: If a claimant hires an attorney, this document outlines the arrangement between the client and attorney regarding representation.

Each of these documents serves a specific purpose in the claims process and contributes to a thorough review of the injury claim. When completing the DD Form 2527, ensuring that these additional documents are prepared and submitted if required will help facilitate the resolution of the claim.

Similar forms

The DD Form 2527 is designed to collect information related to a personal injury and potential third-party liability for medical claims under TRICARE. Similar forms serve various purposes in legal and healthcare contexts. Below are four documents that share similarities with the DD Form 2527.

  • Personal Injury Claim Form: This form is used to declare a personal injury and outline the details related to the incident. Just like the DD Form 2527, it collects information on the injured party, the nature of the injury, and circumstances surrounding the claim. Both forms aim to determine liability and potential compensation for medical expenses incurred due to the injury.
  • Workers' Compensation Claim Form: Workers' compensation forms are filed when employees sustain injuries on the job. Similar to the DD Form 2527, these forms require information about the injury, where it occurred, and related medical treatment. Both serve to ensure that claims are processed efficiently and appropriate benefits are paid to the injured parties.
  • Health Insurance Claim Form (e.g., CMS-1500): This is commonly used in the healthcare industry to request payment for services rendered. Like the DD Form 2527, it requires detailed information about the patient, treatments received, and the related costs. Both documents are essential for facilitating communication between the injured party and insurers, aiding in timely claims processing.
  • Release of Liability Form: This document serves to release one party from legal responsibility for an injury that a claimant may incur. While the DD Form 2527 aims to seek recovery for medical expenses, a Release of Liability form ensures that the claimant understands the implications of waiving their right to sue. Both forms are crucial in the context of legal claims and understanding liabilities associated with injuries.

Understanding these similarities can provide clarity on how various forms interact within legal and healthcare processes, each serving a specific function to ensure the efficient handling of claims and liabilities.

Dos and Don'ts

When completing the DD 2527 form, it’s essential to follow specific guidelines to ensure accurate and timely processing. Here are five things you should and shouldn't do:

  • Do provide accurate information. Double-check names, dates, and relevant details to avoid delays.
  • Do submit the form on time. Return the completed form within 35 days of receipt to prevent claim denial.
  • Do keep copies of your submissions. Maintain a record of what you submitted for your own reference.
  • Do seek assistance if needed. Contact a Judge Advocate office with questions, or consult legal counsel if uncertain.
  • Do follow instructions carefully. Ensure you understand each section of the form as you fill it out.
  • Don't leave any required fields blank. Incomplete forms can lead to processing issues.
  • Don't rush through the process. Take your time to fill out the form accurately and thoughtfully.
  • Don't discuss your case prematurely. Avoid sharing details with anyone without consulting an attorney first.
  • Don't sign without understanding. Only sign the form once you are clear on all the information provided.
  • Don't ignore communication. Respond promptly to any requests from TRICARE regarding your claim.

Misconceptions

Understanding the DD 2527 form can be challenging, and there are several common misconceptions that can lead to confusion. Here are seven of those misconceptions explained:

  1. This form is only for military personnel. Many believe that the DD 2527 is exclusively for active-duty service members. In reality, it applies to their family members as well.
  2. Filling out the form is optional. Some individuals think that completing the DD 2527 is not mandatory. However, failing to submit the form may delay or deny their TRICARE claims.
  3. This form relates to legal actions. There is a misconception that this form is directly tied to any personal injury legal claims. It is primarily for determining third-party liability related to medical expenses, not for legal proceedings.
  4. The processing time is quick. Some assume that submitting the form will immediately expedite their claims process. Instead, processing can take time, and any delays depend on how promptly the completed form is submitted.
  5. Information shared is kept private. While the form includes privacy protection, some individuals wrongly believe that all information will remain confidential. The form allows for certain disclosures in line with privacy laws and government regulations.
  6. Only injuries from accidents are relevant. People often think that only accidents qualify for this form. However, it covers a broad range of personal injuries, including medical malpractice and other incidents.
  7. Submitting the form will automatically initiate legal actions. There is a belief that completing this form will trigger a lawsuit automatically. Submitting the DD 2527 is solely for the purpose of assessing liability for medical costs, not for pursuing legal actions.

Addressing these misconceptions can help individuals navigate the process more effectively and avoid common pitfalls.

Key takeaways

Filling out the DD 2527 form can be crucial for ensuring your medical claims are processed correctly. Here are some key takeaways to consider:

  • The form is essential for allowing the U.S. to recover medical expenses from third parties responsible for your injury.
  • Completing and returning the form within 35 days is necessary to avoid automatic denial of your claim.
  • Accuracy is important; provide all required details, including the nature of your injury and involved parties.
  • Your claims will be put on hold until the form is filled out and submitted, so timely action is vital.
  • For any legal inquiries or advice, consult an attorney instead of taking independent actions regarding injury settlements.

Understanding these pointers can help streamline the claims process and ensure you are properly represented and compensated.