Dd Form 2792 - Family Member Medical Summary (With Instructions) (Page 3 of 13) in pdf

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

ROUTINE USE(S): DoD Blanket Routine Uses 1, 4, 6, 8, 9, 12, and 15 found at

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.

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