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


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.
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
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
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.
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.
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
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.
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