Dd Form 2792 - Family Member Medical Summary (With Instructions) printable pdf download

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

Dd Form 2792 - Family Member Medical Summary (With Instructions)

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