OMB No. 0720-0003
STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY
OMB approval expires
TRICARE MANAGEMENT ACTIVITY
Oct 31, 2010
IF A PREADDRESSED ENVELOPE IS NOT ENCLOSED WITH THIS FORM, PLEASE RETURN YOUR
COMPLETED FORM TO EITHER OF THESE LOCATIONS:
(1) THE TRICARE (TMA) PROCESSOR WHO SENT YOU THE FORM; OR
(2) THE TRICARE (TMA) 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
The public reporting burden for this collection of information is estimated to average 20 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, Executive Services Directorate, Information Management Division, 1155
Defense Pentagon, Washington, DC 20301-1155 (0720-0003). 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: 42 U.S.C. 2651 - 2653; 10 U.S.C. 1079, 1085, 1086 and 1092; and E.O. 9397.
PRINCIPAL PURPOSE(S): To assist in determining possible third party liability for medical supplies and services
claims under TRICARE (previously known as CHAMPUS). Information requested is used in reviewing claims to obtain
additional information to determine proper liability of third parties for claims and to facilitate possible recovery by the
United States for improperly paid claims.
ROUTINE USE(S): Information may be given to the Department of Health and Human Services and/or the
Department of Homeland Security consistent with their statutory administrative responsibilities under TRICARE
(formerly known as CHAMPUS); to the Department of Justice for representation of the Secretary of Defense in civil
actions; to the Internal Revenue Service and private collection agencies in connection with recoupment claims; and to
members of Congress with the consent of the individual involved. Appropriate disclosures may be made to other
Federal, state, local and/or foreign law enforcement agencies, private business entities, and individual providers of
care, on matters relating to entitlement, claims adjudication, 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 (formerly CHAMPUS).
DISCLOSURE: Voluntary; however, failure to provide information will result in a claims processing delay and may
result in denial of the claim.
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, JAN 2008
Page 1 of 2 Pages
PREVIOUS EDITION IS OBSOLETE.
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