DD Form 2527 Statement of Personal Injury - Possible Third Party Liability, Defense Health Agency

What Is DD Form 2527?

DD Form 2527, Statement of Personal Injury - Possible Third Party Liability is an Army form sent out by TRICARE to individuals whose medical expenses may have been a result of injuries caused by a third party.

The liable side may be an individual or a business. If their responsibility is proven, TRICARE will demand reimbursement for its medical costs under the Federal Medical Recovery Act.

The most recent version of the form - commonly referred to as the TRICARE DD Form 2527 - was released by the Department of Defense (DoD) in August 2016 with all previous editions being obsolete. An up-to-date fillable DD Form 2527 is available for download and digital filing below or can be found on the Executive Services Directorate website.

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OMB No. 0720-0003
STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY
OMB approval expires
DEFENSE HEALTH AGENCY
January 31, 2019
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 CFR Part 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): Your records may be disclosed outside of DoD on 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. This includes disclosures to the Departments of Health
and Human Services and Homeland Security consistent with their TRICARE administrative responsibilities, and to the Department of
Veterans Affairs. Your records may also be disclosed to the Internal Revenue Service and private collection agencies in connection
with recoupment claims. Your records may be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974,
as amended, which incorporates the DoD "Blanket Routine Uses" published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Applicable SORN: DTMA 04.
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 by DoD 6025.18-R. Permitted uses and disclosures of PHI include, but
are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary. However, your failure to provide information may result in a claims processing delay and/or the denial of
claims.
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, AUG 2016
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 2 Pages
Adobe LiveCycle Designer ES4
OMB No. 0720-0003
STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY
OMB approval expires
DEFENSE HEALTH AGENCY
January 31, 2019
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 CFR Part 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): Your records may be disclosed outside of DoD on 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. This includes disclosures to the Departments of Health
and Human Services and Homeland Security consistent with their TRICARE administrative responsibilities, and to the Department of
Veterans Affairs. Your records may also be disclosed to the Internal Revenue Service and private collection agencies in connection
with recoupment claims. Your records may be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974,
as amended, which incorporates the DoD "Blanket Routine Uses" published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Applicable SORN: DTMA 04.
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 by DoD 6025.18-R. Permitted uses and disclosures of PHI include, but
are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary. However, your failure to provide information may result in a claims processing delay and/or the denial of
claims.
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, AUG 2016
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 2 Pages
Adobe LiveCycle Designer ES4
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
ARMY
NAVY
AIR FORCE
1. SPONSOR'S SOCIAL SECURITY NUMBER:
COAST GUARD
USPHS
NOAA
2.a. INJURED PATIENT'S NAME:
b. INJURED PATIENT'S ADDRESS:
c. TELEPHONE NUMBER:
3. DATE INJURY OCCURRED (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. LAWYER'S 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)
Page 2 of 2 Pages
DD FORM 2527, AUG 2016
PREVIOUS EDITION OBSOLETE

Download DD Form 2527 Statement of Personal Injury - Possible Third Party Liability, Defense Health Agency

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Where to Mail DD Form 2527?

A copy of the DD Form 2527 will be sent by a regional TRICARE contractor to all individuals who meet any the following criteria:

  • The medical treatment received exceeded $500;
  • The patient was assigned a diagnosis code ranging from 800 to 999;
  • Any inpatient services were rendered.

In ordinary circumstances the form will be sent with a pre-addressed envelope which must then be used to return the completed form to a regional TRICARE office. If an envelope is not included with the paperwork, the DD 2527 must be sent to one of the addresses according to information below:

  1. The mailing address for West Region Claims is at Claims Department (ATTN: New Claims), PO Box 7981, Madison, WI 53707-7981. Call 1-800-444-5445 for more information.

    The East Region includes the following states and territories: Alabama, Arkansas, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa (Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St. Louis area), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina,Tennessee, Texas (excluding El Paso area), Vermont, Virginia, West Virginia, Washington DC and Wisconsin.

  2. Residents of the West Region should send all forms to the Claims Department, P.O. Box 202112, Florence, SC 29502-2112, or call 1-844-866-WEST (9378).

    The West Region includes the following: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excludes Rock Island arsenal area), Kansas, Minnesota, Missouri (except St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (southwestern corner including El Paso), Utah, Washington and Wyoming.

  3. TRICARE For Life Claims in the U.S. and U.S. Territories must be sent to WPS TRICARE For Life, P.O. Box 7890, Madison, WI 53707-7890.

DD Form 2527 Instructions

The form consists of three main sections, a privacy act and an overview of the form. Filing instructions are as follows:

    1. Section I, General Information, requires specifying the sponsor's SSN, branch of service, name, address and telephone number in Boxes 1 and 2. Boxes 3 and 4 are for providing information about the time, date and place where the injury occured.
    2. Section II, Type and Cause of Injury, provides nine different options for the applicant to choose out of to classify the cause of the incident or their injury. The provided options include the following:
      • Box 5 - Traffic Accident;
      • Box 6 - Slip, Fall, Dog Bite or Mishap;
      • Box 7 - Explosion;
      • Box 8 - Assault;
      • Box 9 - Toxic Substance;
      • Box 10 - On-the-job Injury;
      • Box 11 - Product Malfunction;
      • Box 12 - Medical Malpractice;
      • Box 13 - Other Type and Cause of Injury.

      The individual filing the form must select and file the one box that describes their situation best. The space provided in each of the boxes is for providing the necessary additional details about the injury.

    3. Section III, Miscellaneous, is made up of four more items. Boxes 14, 15 and 16 are meant for providing specifics and extra information about the accident, medical facilities and available insurance. Box 17 requires the individual to electronically sign the form and specify the date of signing.

Who Signs DD Form 2527?

The DD Form 2527 must be signed by claimant themself in order for the form to be legally valid.

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