DD Form 2792 Family Member Medical Summary

DD Form 2792, Family Member Medical Summary is Department of Defense-issued form 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 servicemembers of all branches.

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
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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 servicemen 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, servicemembers 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 a 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. Servicemembers 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.
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