Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 4
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13DEMOGRAPHICS/CERTIFICATION: To be completed by the Sponsor, Parent or Guardian, or Patient
1. PURPOSE OF THIS FORM
(X one)
EFMP Registration/Enrollment Update
Request Change in EFMP Status:
Request for Government Sponsored Travel
No Longer Have Previously Identified Condition
Family Member Deceased*
No Longer Qualifies as a Dependent*
Divorce/Change in Custody*
(*Provide documentation to verify change in status - do not update medical information.)
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.a. FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
b. SPONSOR NAME (Last, First, Middle Initial)
c. SPONSOR SSN
e. FAMILY MEMBER DATE OF BIRTH
g. DOD BENEFITS NUMBER (DBN)
d. FAMILY MEMBER GENDER (X)
f. FAMILY MEMBER PREFIX (FMP)
(YYYYMMDD)
(on back of ID Card)
Male
Female
h. CURRENT FAMILY MEMBER MAILING ADDRESS (Street, Apartment Number, City,
i. HOME TELEPHONE NUMBER (Include Area Code/Country Code)
State, ZIP Code, APO/FPO)
j. FAMILY HOME E-MAIL ADDRESS
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b. DESIGNATION/NEC/MOS/AFSC (Military only)
c. INSTALLATION OF SPONSOR'S CURRENT ASSIGNMENT
.a. SPONSOR RANK OR GRADE
d. BRANCH OF SERVICE (Military only)
e. STATUS (X one)
Active Reserve
Active Guard
Army
Navy
Air Force
Regular Active Service Member
Marine Corps
Coast Guard
Reserves
National Guard
Civilian
g. DUTY TELEPHONE NUMBER
h. MOBILE NUMBER
f. SPONSOR'S OFFICIAL E-MAIL ADDRESS
(Include Area Code/Country Code)
(Include Area Code/Country Code)
i. DOES CHILD RESIDE WITH SPONSOR? (X one. If No, explain.)
YES
NO
4.
a. ARE YOU DUAL MILITARY OR IS YOUR SPOUSE FORMER MILITARY? (Military only) (X one. If Yes, complete 4.b. - e. below)
YES
b. SPOUSE'S NAME (Last, First, Middle Initial)
c. BRANCH OF SERVICE
d. RANK/RATE
e. SPOUSE SSN
NO
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.a. IS FAMILY MEMBER ENROLLED IN DEERS OR EVER BEEN ENROLLED IN DEERS UNDER A DIFFERENT SPONSOR'S NAME OR SSN? (Military only) (X one)
YES
b. IF YES, UNDER WHAT SSN?
c. NAME OF SPONSOR (Last, First, Middle Initial)
d. BRANCH OF SERVICE
NO
6.a. DOES THIS FAMILY MEMBER RECEIVE CASE MANAGEMENT SERVICES?
(X one)
YES
NO (If Yes, complete 9.b. and c.)
b. LOCATION OF CASE MANAGER (X)
MTF
TRICARE
Civilian
c. CASE MANAGER CONTACT INFORMATION
(3) TELEPHONE NUMBER (Include
(1) NAME (Last, First, Middle Initial)
(2) EMAIL ADDRESS (If available)
Area Code/Country Code)
7. MEDICALLY NECESSARY EQUIPMENT
(X and complete as applicable)
If applicable: (1) MAKE
(2) MODEL
a. COCHLEAR IMPLANT
If applicable: (1) MAKE
(2) MODEL
b. HEARING AIDS
If applicable: (1) MAKE
(2) MODEL
c. INSULIN PUMP
If applicable: (1) MAKE
(2) MODEL
d. PACEMAKER
e. OTHER EQUIPMENT (Specify and include make and model as appropriate.)
DD FORM 2792, AUG 2014
Page 2 of 11 Pages
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