Filing CHCBP claims

If you have to file your own claim, you should send your claim form as soon as possible after you receive care. The sooner your claim and other paperwork are received, the sooner you or your provider will be paid. In the US and US territories, claims must be filed within one year of service. In all other overseas areas, claims must be filed within three years of service.

  1. Download and fill out the Patient's Request for Medical Payment (DD Form 2642)
  2. Attach a readable copy of the provider's bill to the form, making sure it contains the following:
    • Sponsor's Social Security Number (SSN) (eligible former spouses should use their SSN)
    • Provider's name and address (if more than one provider's name is on the bill, circle the name of the person who treated you)
    • Date and place of each service
    • Description of each service or supply furnished
    • Charge for each service
    • Diagnosis (if the diagnosis is not on the bill, be sure to complete block 8a on the form)
  3. Fill out all 12 blocks of the form correctly and sign it
  4. Attach a copy of your CHCBP ID card
  5. Make a copy of the paperwork for your records
  6. Mail your completed claim form to:
  7. CHCBP Claims
    PO Box 7981
    Madison, WI 53707-7981

*If submitting a claim for prescriptions, mail to:

Express Scripts
ATTN: CHCBP Pharmacy Claims
PO Box 52132
Phoenix, AZ 85072