DD Form 2792 Family Member Medical Summary

DD Form 2792, Family Member Medical Summary is a form issued by the Department of Defense (DoD) and used for enrollment in the EFMP and for recording a family member's special need for medical services.

This form - often confused with DA Form 2792 - was previously reviewed in August 2014 with all previous editions being obsolete. An up-to-date fillable version of the DD 2792 is available for download below or through the DoD Documentation website.

What Is DD Form 2792?

The information provided in the Family Member Medical Summary will help the military assignment personnel determine how the dependent's special needs may be met in accordance with the availability of medical services at a particular duty station.

The form is a part of a paperwork package necessary to enroll into the Exceptional Family Member Program - or EFMP for short - and for the Family Member Travel Screening Process along with the DD Form 2792-1, Special Education/Early Intervention Summary.

Despite being issued by the Department of Defense, DD Form 2792 and DD 2792-1 are required for EFMP enrollment for service members of all branches.

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INSTRUCTIONS FOR COMPLETING DD FORM 2792,
FAMILY MEMBER MEDICAL SUMMARY
GENERAL.
Items 10.a. - c. To be completed by the administrator in consultation with
the family. Mark (X) all services being provided to the family member.
The DD Form 2792 and attached addenda are completed to identify a
family member with special medical needs.
Items 11.a. - c. Parent/Guardian or Person of Majority Age. Parent/
There is a Certification Section on page 3 that should be signed
guardian or person of majority age certifies that the information contained
AFTER the entire form is completed by medical provider(s) and the form
in the DD 2792 is correct. Individual must ensure that all applicable
has been reviewed for completeness and accuracy.
forms are completed and attached before signing.
The Parent/Guardian or Person of Majority Age signs block 11b, and
the MTF coordinator/authorized reviewer signs block 12b.
Items 12.a. - f. The MTF authorized case coordinator/administrator
A Qualified Medical Provider is responsible for assessing whether
name, signature, date, location of military treatment facility or certifying
the services they are eligible to prescribe are within the scope of their
EFMP program, telephone number, and official stamp. Self-explanatory.
practice and their state licensing requirements.
Administrator must ensure that all forms are complete and attached
before signing.
AUTHORIZATION FOR DISCLOSURE (Page 1)
MEDICAL SUMMARY beginning on page 4 must be completed by a
Health Insurance Portability and Accountability Act (HIPAA)
qualified medical professional. Sponsor, spouse, or family member
Requirement.
of majority age must sign release authorization on page 1 before
Each adult family member must sign for the release of his/her own
this summary is completed. Please complete as accurately as possible
medical information. The sponsor or spouse cannot authorize the release
using ICD-9-CM or, when approved, ICD-10-CM. If the patient has an
of information for those dependent family members who have reached the
asthma, mental health or autism spectrum disorder/developmental delay
age of majority unless they are court-appointed guardians. Please
diagnosis, enter ONLY the diagnostic description/code on Page 4 and the
consult with your military treatment facility (MTF) or dental treatment
remainder of the information on the appropriate attached addendum form.
facility (DTF) privacy/HIPAA coordinator about questions regarding
authorizations for disclosure.
Items 1.a. - c. Place an "X" in the appropriate box if the information is
DEMOGRAPHICS/CERTIFICATION (Page 2).
included in an addendum.
Item 1. Self-explanatory.
Items 2.a. - b. Primary Diagnosis. Enter the primary diagnosis and
corresponding diagnostic code for the family member.
Item 2.a. Family Member (FM). Name of family member described in
subsequent pages.
Items 3.a. - c. Medication History. Enter all current medications
Item 2.b. Sponsor Name. Name of the military member responsible for
associated with the primary diagnosis, the dosage and frequency
the family member identified in Item 2.a.
medication should be taken.
Items 2.c. - e. Self-explanatory.
Item 2.f. Family Member Prefix (FMP). Applies to Miliitary medical
Items 4.a. - d. Hospital Support for the Last 12 Months. Enter the
beneficiary only. The Family Member Prefix is assigned when the family
number of emergency room visits/urgent care visits, hospitalizations, ICU
member is enrolled in DEERS.
admissions, and number of outpatient visits.
Item 2.g. DoD Benefits Number (DBN). This 11-digit number has two
components. The first nine digits are assigned to the sponsor; the last
Item 5. Prognosis. Self-explanatory.
two digits identify the specific person covered under that sponsor. The
first nine digits do not reflect the sponsor's nine-digit SSN. The DBN can
Item 6. Treatment Plan for Primary Diagnosis. Include medical and/or
be found above the bar code on the back of the beneficiary's ID card. If
surgical procedures, special therapies planned or recommended over the
the child has not been issued an ID card, enter the first 9 digits of the
next three years. Also include the expected length of treatment, required
parent's DBN.
participation of family members, and if treatment is ongoing.
Items 2.h. - j. Self-explanatory.
Items 7. - 21. Secondary Diagnoses. Follow procedures for Items 2. - 6.
Items 3.a. - h. All items refer to the sponsor. Self-explanatory.
above.
Item 3.i. Annotate with an "X" whether the family member resides with
the sponsor. If the family member does not, then provide an explanation.
Item 22. Minimum Health Care Required. Codes in the first column are
Item 4.a. Answer Yes if both spouses are on active duty or if the
used by Army coding teams only. In column 1, mark with an X any
enrolling spouse was a former member of the U.S. military. If Yes,
specialists REQUIRED to meet the patient's needs. If a specialist was
complete Items 4.b. - e.
used to determine a diagnosis, and is not necessary for ongoing care, DO
NOT place an X next to that specialist. If a developmental pediatrician is
Item 5.a. - d. If Yes, enter SSN, name of sponsor and branch of Service.
a child's primary care manager, but a pediatrician meets the needs, DO
Military only.
NOT mark developmental pediatrician. This section is not a wish list, but
should reflect the providers that are necessary to meet the needs of the
Item 6.a. If Yes, complete b. - c. Self-explanatory.
patient.
Item 7. Identify current medically necessary adaptive equipment or
Items 23. - 26. Self-explanatory.
special medical equipment used by the family member. Include make
and model of the equipment.
Items 27.a. - f. Provider Information. Official stamp or printed name and
signature of the provider completing this summary, date the summary
Item 8. Required Actions. Self-explanatory.
was signed, telephone number(s) for the provider, email and medical
specialty.
Item 9. Required Addenda. To be completed by the EFMP/Screening
Coordinator completing the administrative review/certification. Please
note: Each addenda is completed, and submitted for EFMP review, only
if applicable to the patient described. SIGNATURE of a Qualified
Medical Provider is REQUIRED.
DD FORM 2792 INSTRUCTIONS, AUG 2014
Page i
INSTRUCTIONS FOR COMPLETING DD FORM 2792,
FAMILY MEMBER MEDICAL SUMMARY
GENERAL.
Items 10.a. - c. To be completed by the administrator in consultation with
the family. Mark (X) all services being provided to the family member.
The DD Form 2792 and attached addenda are completed to identify a
family member with special medical needs.
Items 11.a. - c. Parent/Guardian or Person of Majority Age. Parent/
There is a Certification Section on page 3 that should be signed
guardian or person of majority age certifies that the information contained
AFTER the entire form is completed by medical provider(s) and the form
in the DD 2792 is correct. Individual must ensure that all applicable
has been reviewed for completeness and accuracy.
forms are completed and attached before signing.
The Parent/Guardian or Person of Majority Age signs block 11b, and
the MTF coordinator/authorized reviewer signs block 12b.
Items 12.a. - f. The MTF authorized case coordinator/administrator
A Qualified Medical Provider is responsible for assessing whether
name, signature, date, location of military treatment facility or certifying
the services they are eligible to prescribe are within the scope of their
EFMP program, telephone number, and official stamp. Self-explanatory.
practice and their state licensing requirements.
Administrator must ensure that all forms are complete and attached
before signing.
AUTHORIZATION FOR DISCLOSURE (Page 1)
MEDICAL SUMMARY beginning on page 4 must be completed by a
Health Insurance Portability and Accountability Act (HIPAA)
qualified medical professional. Sponsor, spouse, or family member
Requirement.
of majority age must sign release authorization on page 1 before
Each adult family member must sign for the release of his/her own
this summary is completed. Please complete as accurately as possible
medical information. The sponsor or spouse cannot authorize the release
using ICD-9-CM or, when approved, ICD-10-CM. If the patient has an
of information for those dependent family members who have reached the
asthma, mental health or autism spectrum disorder/developmental delay
age of majority unless they are court-appointed guardians. Please
diagnosis, enter ONLY the diagnostic description/code on Page 4 and the
consult with your military treatment facility (MTF) or dental treatment
remainder of the information on the appropriate attached addendum form.
facility (DTF) privacy/HIPAA coordinator about questions regarding
authorizations for disclosure.
Items 1.a. - c. Place an "X" in the appropriate box if the information is
DEMOGRAPHICS/CERTIFICATION (Page 2).
included in an addendum.
Item 1. Self-explanatory.
Items 2.a. - b. Primary Diagnosis. Enter the primary diagnosis and
corresponding diagnostic code for the family member.
Item 2.a. Family Member (FM). Name of family member described in
subsequent pages.
Items 3.a. - c. Medication History. Enter all current medications
Item 2.b. Sponsor Name. Name of the military member responsible for
associated with the primary diagnosis, the dosage and frequency
the family member identified in Item 2.a.
medication should be taken.
Items 2.c. - e. Self-explanatory.
Item 2.f. Family Member Prefix (FMP). Applies to Miliitary medical
Items 4.a. - d. Hospital Support for the Last 12 Months. Enter the
beneficiary only. The Family Member Prefix is assigned when the family
number of emergency room visits/urgent care visits, hospitalizations, ICU
member is enrolled in DEERS.
admissions, and number of outpatient visits.
Item 2.g. DoD Benefits Number (DBN). This 11-digit number has two
components. The first nine digits are assigned to the sponsor; the last
Item 5. Prognosis. Self-explanatory.
two digits identify the specific person covered under that sponsor. The
first nine digits do not reflect the sponsor's nine-digit SSN. The DBN can
Item 6. Treatment Plan for Primary Diagnosis. Include medical and/or
be found above the bar code on the back of the beneficiary's ID card. If
surgical procedures, special therapies planned or recommended over the
the child has not been issued an ID card, enter the first 9 digits of the
next three years. Also include the expected length of treatment, required
parent's DBN.
participation of family members, and if treatment is ongoing.
Items 2.h. - j. Self-explanatory.
Items 7. - 21. Secondary Diagnoses. Follow procedures for Items 2. - 6.
Items 3.a. - h. All items refer to the sponsor. Self-explanatory.
above.
Item 3.i. Annotate with an "X" whether the family member resides with
the sponsor. If the family member does not, then provide an explanation.
Item 22. Minimum Health Care Required. Codes in the first column are
Item 4.a. Answer Yes if both spouses are on active duty or if the
used by Army coding teams only. In column 1, mark with an X any
enrolling spouse was a former member of the U.S. military. If Yes,
specialists REQUIRED to meet the patient's needs. If a specialist was
complete Items 4.b. - e.
used to determine a diagnosis, and is not necessary for ongoing care, DO
NOT place an X next to that specialist. If a developmental pediatrician is
Item 5.a. - d. If Yes, enter SSN, name of sponsor and branch of Service.
a child's primary care manager, but a pediatrician meets the needs, DO
Military only.
NOT mark developmental pediatrician. This section is not a wish list, but
should reflect the providers that are necessary to meet the needs of the
Item 6.a. If Yes, complete b. - c. Self-explanatory.
patient.
Item 7. Identify current medically necessary adaptive equipment or
Items 23. - 26. Self-explanatory.
special medical equipment used by the family member. Include make
and model of the equipment.
Items 27.a. - f. Provider Information. Official stamp or printed name and
signature of the provider completing this summary, date the summary
Item 8. Required Actions. Self-explanatory.
was signed, telephone number(s) for the provider, email and medical
specialty.
Item 9. Required Addenda. To be completed by the EFMP/Screening
Coordinator completing the administrative review/certification. Please
note: Each addenda is completed, and submitted for EFMP review, only
if applicable to the patient described. SIGNATURE of a Qualified
Medical Provider is REQUIRED.
DD FORM 2792 INSTRUCTIONS, AUG 2014
Page i
INSTRUCTIONS FOR COMPLETING DD FORM 2792
(Continued)
ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE SUMMARY
ADDENDUM 3 - AUTISM SPECTRUM DISORDERS AND
(p. 8). To be completed by a qualified medical professional. This
SIGNIFICANT DEVELOPMENTAL DELAYS (p.11) . To be
addendum is completed only if applicable to the patient described.
completed by a qualified medical professional. This addendum
is completed only if applicable to the patient described.
Item 1. Diagnostic Description Code. Enter the diagnostic description
code (ICD-9-CM or, when approved, ICD-10-CM) for patients evaluated
Item 1.a. - c. Indicate the diagnosis(es) using an X. Insert the date
or treated for asthma within the past 5 years and continue the
when diagnosed and select the appropriate specialty provider(s) or
completion of the addendum and sign. Signature of Qualified Medical
school-based team that diagnosed the patient.
Provider is REQUIRED in Item 5.b.
Items 2. - 3. Self-explanatory.
Items 2. - 4. Self-explanatory.
Items 4.a. - d. Current Medications. List all current medications
Item 5.a. - f. Provider Information. Official stamp or printed name and
used to treat the diagnosis(es) listed in Items 1 and 3, the dosage,
signature of the provider completing this addendum, the date the
the frequency taken, and the reason prescribed.
summary was signed, the telephone number(s) for the provider, email,
and medical specialty.
Items 5.a. - e. Current Interventions/Therapies. Providing a list of
current interventions and therapies is important information for the
family travel determination for this patient. The information should
ADDENDUM 2 - MENTAL HEALTH SUMMARY (pp. 9 - 10). To be
be completed by a qualified medical professional in consultation
completed and signed by a qualified medical professional. This
with the family. Self-explanatory.
addendum is completed only if applicable to the patient described.
Item 6. Communication. Using an X, indicate if the patient is verbal
Items 1.a. - c. Diagnosis(es). Complete as accurately as possible
or non-verbal. If non-verbal, indicate the appropriate
using ICD-9-CM or, when approved, ICD-10-CM if the patient has
communication methods used.
current or past (within the last 5 years) history of mental health
diagnosis (to include attention deficit disorders).
Item 7. Self-explanatory.
Items 2.a. - c. Medication History. Provide current medications,
Item 8. Behavior. Answer yes if the child exhibits high risk or
dosage, and frequency for diagnoses listed in Item 1.a.
dangerous behaviors. Additional information may be included in
item 13 if more space is required.
Items 2.d. - e. Include any discontinued medication(s) related to the
diagnosis(es), with reasons for discontinuing, and the frequency taken.
Item 9. Cognitive Ability. Indicate appropriate intelligence quotient
(IQ), if known.
Items 3.a. - b. Therapy Received or Recommended. Include past
compliance with treatment programs, frequency and expected length of
Items 10. - 11. Self-explanatory.
treatment, required participation of family members, and if treatment is
ongoing.
Item 12. Respite Care Received. Provide the number of hours per
month, and the source, e.g., EFMP Respite Care Program, ECHO
Items 4.a. - c. Treatment. Insert the number of outpatient visits in the
or Medicaid.
LAST YEAR, the number of hospitalizations in the LAST FIVE YEARS,
and the number of residential treatment admissions in the LAST FIVE
Item 13. General Comments. Self-explanatory.
YEARS (include the date of last admission).
Item 14. Provider Information. Official Stamp or printed name,
Items 5.a. - h. History. Answer Yes or No, and include additional
signature, date signed, telephone number(s), official email and
details as directed on the patient's mental health history for the last five
medical specialty. Self-explanatory.
years.
Items 6. - 9. Self-explanatory.
Items 10.a. - f. Provider Information. Official stamp or printed name
and signature of the provider completing this addendum, the date the
summary was signed, the telephone number(s) for the provider, email
and medical specialty.
DD FORM 2792 INSTRUCTIONS (BACK), AUG 2014
Page ii
OMB No. 0704-0411
FAMILY MEMBER MEDICAL SUMMARY
(To be completed by service member, adult family member, or civilian employee.)
OMB approval expires
(Read Instructions before completing this form.)
Jul 31, 2017
The public reporting burden for this collection of information is estimated to average 30 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, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0411). 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. 136; 20 U.S.C. 927; DoDI 1315.19: DoDI 1342.12; and E.O. 9397 (SSN) as amended.
PRINCIPAL PURPOSE(S): Information will be used by DoD personnel to evaluate and document the special medical needs of family members. This
information will enable: (1) military assignment personnel to match the special medical needs of family members against the availability of medical
services, and (2) civilian personnel officers to advise civilian employees about the availability of medical services to meet the special medical needs of
their family members. The personally identifiable information collected on this form is covered by a number of system of records notices pertaining to
Official Military Personnel Files, Exceptional Family Member or Special Needs files, Civilian Personnel Files, and DoD Education Activity files. The SORNs
may be found at http://dpclo.defense.gov/Privacy/SORNSIndex/DODComponentNotices.aspx.
ROUTINE USE(S): DoD Blanket Routine Uses 1, 4, 6, 8, 9, 12, and 15 found at http://dpclo.defense.gov/Privacy/SORNSIndex/BlanketRoutineUses.aspx
may apply.
DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment. Mandatory for military personnel: failure or refusal to provide the
information or providing false information may result in administrative sanctions or punishment under either Article 92 (dereliction of duty) or Article 107
(false official statement), Uniform Code of Military Justice. The Social Security Number of the sponsor (and sponsor's spouse if dual military) allows the
Military Healthcare System and Service personnel offices to work together to ensure any special medical needs of your dependent can be met at your next
duty assignment. Dependent special needs are annotated in the official military personnel files which are retrieved by name and Social Security Number.
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
By signing this authorization, you confirm you understand your sponsor will have access to the health information contained herein and in addenda. The
sponsor may be held accountable for the accuracy and completeness of the DD 2792 and addenda and should review all pages prior to signing on page 2.
I authorize
(MTF/DTF/Civilian Provider) (Name of Provider)
to release my patient information to the Relocation or Suitability Screening Office and/or the Exceptional Family Member/Special Needs Program to be used
in the family travel review process and/or registration in the Exceptional Family Member Program. The information on this form and addenda may be used
for DoD and Service-specific programs to determine whether there are adequate medical, housing and community resources to meet your medical needs at
the sponsor's proposed duty locations.
a. The military medical department will use the information to determine recommendations on the availability of care in communities where the sponsor may
be assigned or employed.
b. Information that you have a special need (not the nature or scope of the need) may be included in the sponsor's personnel record or be maintained in the
community office responsible for supporting families with special needs, if EFMP enrollment criteria are met.
c. The authorization applies to the summary data included on the medical summary form, its addenda and subsequent updates to information on this form.
These data may be stored in electronic databases used for medical management or dedicated to the assignment process. Access to the information is
limited to representatives from the medical departments, the offices responsible for assignment coordination, and at your request other military agents
responsible for care or services. Summary data may be transmitted (e.g., faxing or emailing) using authorized secure media transfer.
Start Date: The authorization start date is the date that you sign this form authorizing release of information.
Expiration Date: The authorization shall continue until enrollment in the Exceptional Family Member Program is no longer necessary according to criteria
specified in DoD Instruction 1315.19, or if family member no longer meets the criteria to qualify as a dependent, or the sponsor is no longer in active military
service or employment of the U.S. Government overseas, or completion of assignment coordination, or eligibility determination for specialized services if that
is the sole purpose for the completion of the form.
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my or my child's medical
records are kept. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed protected information on
the basis of this authorization. My revocation will have no impact on disclosures made prior to the revocation.
b. If I authorize my or my child's protected health information to be disclosed to someone who is not required to comply with federal privacy protection
regulations, then such information may be re-disclosed and would no longer be protected.
c. I have a right to inspect and receive a copy of my own or my child's protected health information to be used or disclosed, in accordance with the
requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524. I request and authorize the named provider/
treatment facility to release the information described above for the stated purposes.
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health
Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization. However, failure to
coordinate accompanied assignments prior to OCONUS travel may result in ineligibility for TRICARE Prime status (does not pertain to civilian employees).
e. Failure to release this information or any subsequent revocation may result in ineligibility for accompanied family travel at government expense.
f. Refusal to sign does not preclude the provision of medical and dental information authorized by other regulations and those noted in this document.
RELATIONSHIP TO PATIENT
NAME OF PATIENT
SIGNATURE OF PATIENT/PARENT/GUARDIAN
DATE
(YYYYMMDD)
(If applicable)
DD FORM 2792, AUG 2014
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 11 Pages
Adobe Designer 9.0
DEMOGRAPHICS/CERTIFICATION: To be completed by the Sponsor, Parent or Guardian, or Patient
1. PURPOSE OF THIS FORM
(X one)
EFMP Registration/Enrollment Update
Request Change in EFMP Status:
Request for Government Sponsored Travel
No Longer Have Previously Identified Condition
Family Member Deceased*
No Longer Qualifies as a Dependent*
Divorce/Change in Custody*
(*Provide documentation to verify change in status - do not update medical information.)
2
.a. FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
b. SPONSOR NAME (Last, First, Middle Initial)
c. SPONSOR SSN
e. FAMILY MEMBER DATE OF BIRTH
g. DOD BENEFITS NUMBER (DBN)
d. FAMILY MEMBER GENDER (X)
f. FAMILY MEMBER PREFIX (FMP)
(YYYYMMDD)
(on back of ID Card)
Male
Female
h. CURRENT FAMILY MEMBER MAILING ADDRESS (Street, Apartment Number, City,
i. HOME TELEPHONE NUMBER (Include Area Code/Country Code)
State, ZIP Code, APO/FPO)
j. FAMILY HOME E-MAIL ADDRESS
3
b. DESIGNATION/NEC/MOS/AFSC (Military only)
c. INSTALLATION OF SPONSOR'S CURRENT ASSIGNMENT
.a. SPONSOR RANK OR GRADE
d. BRANCH OF SERVICE (Military only)
e. STATUS (X one)
Active Reserve
Active Guard
Army
Navy
Air Force
Regular Active Service Member
Marine Corps
Coast Guard
Reserves
National Guard
Civilian
g. DUTY TELEPHONE NUMBER
h. MOBILE NUMBER
f. SPONSOR'S OFFICIAL E-MAIL ADDRESS
(Include Area Code/Country Code)
(Include Area Code/Country Code)
i. DOES CHILD RESIDE WITH SPONSOR? (X one. If No, explain.)
YES
NO
4.
a. ARE YOU DUAL MILITARY OR IS YOUR SPOUSE FORMER MILITARY? (Military only) (X one. If Yes, complete 4.b. - e. below)
YES
b. SPOUSE'S NAME (Last, First, Middle Initial)
c. BRANCH OF SERVICE
d. RANK/RATE
e. SPOUSE SSN
NO
5
.a. IS FAMILY MEMBER ENROLLED IN DEERS OR EVER BEEN ENROLLED IN DEERS UNDER A DIFFERENT SPONSOR'S NAME OR SSN? (Military only) (X one)
YES
b. IF YES, UNDER WHAT SSN?
c. NAME OF SPONSOR (Last, First, Middle Initial)
d. BRANCH OF SERVICE
NO
6.a. DOES THIS FAMILY MEMBER RECEIVE CASE MANAGEMENT SERVICES?
(X one)
YES
NO (If Yes, complete 9.b. and c.)
b. LOCATION OF CASE MANAGER (X)
MTF
TRICARE
Civilian
c. CASE MANAGER CONTACT INFORMATION
(3) TELEPHONE NUMBER (Include
(1) NAME (Last, First, Middle Initial)
(2) EMAIL ADDRESS (If available)
Area Code/Country Code)
7. MEDICALLY NECESSARY EQUIPMENT
(X and complete as applicable)
If applicable: (1) MAKE
(2) MODEL
a. COCHLEAR IMPLANT
If applicable: (1) MAKE
(2) MODEL
b. HEARING AIDS
If applicable: (1) MAKE
(2) MODEL
c. INSULIN PUMP
If applicable: (1) MAKE
(2) MODEL
d. PACEMAKER
e. OTHER EQUIPMENT (Specify and include make and model as appropriate.)
DD FORM 2792, AUG 2014
Page 2 of 11 Pages
FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
FOR ADMINISTRATIVE USE ONLY
8. REQUIRED ACTIONS
(X one)
First Review of Medical History for the Family Member
Qualifies for Change in EFMP Status:
Family Member No Longer Has Previously
Request for Government Sponsorship/Family Travel
Family Member Deceased*
Identified Condition
Family Member No Longer Qualifies as a
Update to a Previous Evaluation for the Family Member
Divorce/Change in Custody*
Dependent*
Other (e.g., Extended Care Health Option Eligibility):
(*Maintain documentation to verify change in status - do not update medical information.)
9. REQUIRED ADDENDA.
Verify required addendum is attached and has been signed
. Do not submit a blank addendum for EFMP review.
(X each that applies)
Asthma Addendum 1 is required and
Attached.
Mental Health Summary Addendum 2 is required and
Attached.
Autism Spectrum Disorder/Developmental Delay (AS/DD) Addendum 3 is required and
Attached.
10. SPECIAL ASSIGNMENT CONSIDERATIONS
(X all that apply)
a. Possible Special Education/Early Intervention (If checked, DD Form 2792-1 must be completed)
b. Receiving TRICARE Extended Care Health Option (ECHO) Benefits
c. Receiving State Medicaid/Medicare Waiver Services
CERTIFICATION
11. CERTIFICATION. DO NOT CERTIFY BEFORE THE MEDICAL PROVIDER COMPLETES THE ENTIRE FORM AND ADDENDA.
By signing below, we certify that the information submitted on this DD Form 2792 is complete and accurate.
PARENT/GUARDIAN OR PERSON OF MAJORITY AGE:
a. PRINTED NAME
b. SIGNATURE
c. DATE (YYYYMMDD)
12. ADMINISTRATIVE CERTIFICATION
a. PRINTED NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE (YYYYMMDD)
f. OFFICIAL STAMP
e. TELEPHONE NUMBER
d. LOCATION OF MILITARY TREATMENT FACILITY OR CERTIFYING EFMP OFFICE
(Include area code/Country Code)
DD FORM 2792, AUG 2014
Page 3 of 11 Pages

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The Exceptional Family Member Program (EFMP)

The EFMP is a program implemented by the United States Department of Defense and provides support and various services to U.S. military family members with special needs. This includes spouses, children, and dependent adults. The proper forms should be completed by a sponsor, spouse, primary care provider, or by school personnel.

EFMP enrollment is available for service members in any military branch, and each branch of service is capable of providing a wide range of medical, educational, personnel, and family support functions.

Military members enroll in the program if they have one or more family members with a diagnosed physical, intellectual, developmental, or psychological condition that needs specialized attention, medical care or educational services.

To confirm enrollment, service members need to file DD 2792 and DD 2792-1 forms and submit them with all necessary attachments to an Army Medical Treatment Facility (MTF). The EFMP Case Coordinator will then conduct an administrative review of the provided forms and forwards them to the appropriate Regional Health Command (RHC).

The RHC reviews the documents and determines eligibility. If the application is approved, the RHC downloads the data into the EFMP database on the Army Personnel Network. After that, the Case Coordinator will inform the Soldier about their successful enrollment.

DD Form 2792 Instructions

The first two pages of the form provide you with instructions for filling the form and a basic description of each of the sections.

  1. Enter the name of the Medical or Dental Treatment Facility, the Civilian provider who will be in charge of completing your enrollment or update in the fillable box on the first page of the actual form.
  2. Input the name of the family member enrolling in the program at the bottom of the same page. If you want to enroll a child, either the parent, the sponsor or an alternative guardian must provide their signature, state their relationship and date the page. If the person being enrolled is 18 and older, they must sign the form and describe their relationship status as SELF in the appropriate box.
  3. State the purpose of filing in Box 1. Provide your own personal identifying information and the information about the dependent. Then describe their medical needs in the appropriate Box on page 2.
  4. Most of the third page is to be filed by administrative personnel within the EFMP. Make sure that the name of the enrollee, the name of the sponsor and the last four digits of the sponsor's SSN at the top of every page.
  5. Pages 4 through 7 are to be filled by a qualified medical professional. After your health care provider has completed the DD Form 2792, review Box 11 for accuracy. You must certify the form with your signature and date it everything is accurate and complete.
  6. Pages 8 is only applicable if the enrolled family member was diagnosed with asthma or reactive airway disease. Pages 9 and 10 are applicable only in case if the enrolled family member has a mental health diagnosis. Page 11 is only applicable if the dependent has a disorder on the autism spectrum or significant developmental delays. These pages must only be completed by a qualified care provider.

How Often Should I Update My DD Form 2792?

Enrollment should be updated every 3 years or upon any changes in the medical condition of the enrolled family member. Service members are advised to start the update process at least 90 days prior to the expiration date to ensure sufficient time for the updating process.

Where to Go to Get a DD Form 2792 Filled?

Click the link above to download a fillable copy of the DD 2792 or fill it out digitally. Alternatively, you can visit your local EFMP office and ask a Family Case Worker to provide you with a physical copy of the form or have it faxed to you.

EFMP Enrollment Forms

Army Forms for Family Member Travel Screening:

Air Force Enrollment Form:

  • AF Form 2523, Exceptional Family Member Program - Medical Information Form (EFMP-M).

Air Force Family Member Travel Screening Forms:

Navy forms and Marine Corps Family Member Travel Screening Forms:

  • NAVMED Form 13001, Medical, Dental and Educational Suitability Screening for Service and Family Members;
  • NAVMED Form 13002, Medical, Dental and Educational Suitability Screening Checklist and Worksheet;
  • NAVPERS Form 130016, Report of Suitability for Overseas Assignment.

Related forms

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