Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 5
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13FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
FOR ADMINISTRATIVE USE ONLY
8. REQUIRED ACTIONS
(X one)
First Review of Medical History for the Family Member
Qualifies for Change in EFMP Status:
Family Member No Longer Has Previously
Request for Government Sponsorship/Family Travel
Family Member Deceased*
Identified Condition
Family Member No Longer Qualifies as a
Update to a Previous Evaluation for the Family Member
Divorce/Change in Custody*
Dependent*
Other (e.g., Extended Care Health Option Eligibility):
(*Maintain documentation to verify change in status - do not update medical information.)
9. REQUIRED ADDENDA.
Verify required addendum is attached and has been signed
. Do not submit a blank addendum for EFMP review.
(X each that applies)
Asthma Addendum 1 is required and
Attached.
Mental Health Summary Addendum 2 is required and
Attached.
Autism Spectrum Disorder/Developmental Delay (AS/DD) Addendum 3 is required and
Attached.
10. SPECIAL ASSIGNMENT CONSIDERATIONS
(X all that apply)
a. Possible Special Education/Early Intervention (If checked, DD Form 2792-1 must be completed)
b. Receiving TRICARE Extended Care Health Option (ECHO) Benefits
c. Receiving State Medicaid/Medicare Waiver Services
CERTIFICATION
11. CERTIFICATION. DO NOT CERTIFY BEFORE THE MEDICAL PROVIDER COMPLETES THE ENTIRE FORM AND ADDENDA.
By signing below, we certify that the information submitted on this DD Form 2792 is complete and accurate.
PARENT/GUARDIAN OR PERSON OF MAJORITY AGE:
a. PRINTED NAME
b. SIGNATURE
c. DATE (YYYYMMDD)
12. ADMINISTRATIVE CERTIFICATION
a. PRINTED NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE (YYYYMMDD)
f. OFFICIAL STAMP
e. TELEPHONE NUMBER
d. LOCATION OF MILITARY TREATMENT FACILITY OR CERTIFYING EFMP OFFICE
(Include area code/Country Code)
DD FORM 2792, AUG 2014
Page 3 of 11 Pages
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