Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 2

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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

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