Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 6

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FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
MEDICAL SUMMARY: To be completed by a Qualified Medical Professional
PART A - PATIENT STATUS
(Authorization by patient or parent/guardian included on Page 1 of this form)
Please complete as accurately as possible using ICD-9-CM or, when approved, ICD-10-CM. If the patient has an asthma, mental health, or autism
spectrum disorder/developmental delay diagnosis, enter ONLY the diagnostic description/code on this page and the remainder of the information on
the appropriate attached addendum form.
1. INFORMATION INCLUDED IN ADDENDUM
(X all that apply)
a. Asthma (Addendum 1)
b. Mental Health/ADHD (Addendum 2)
c. Autism/Developmental Delay (AS/DD) (Addendum 3)
2. PRIMARY DIAGNOSIS
a. DIAGNOSIS
b. CODE
.
3. MEDICATION HISTORY
(Associated with primary diagnosis)
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
4. HOSPITAL SUPPORT FOR THE LAST 12 MONTHS
(Associated with primary diagnosis)
a. NUMBER OF ER VISITS/URGENT
d. NUMBER OF OUTPATIENT
b. NUMBER OF HOSPITALIZATIONS
c. NUMBER OF ICU ADMISSIONS
CARE VISITS
VISITS
5. PROGNOSIS
(X one)
EXCELLENT
GOOD
FAIR
POOR
GUARDED
UNSTABLE
NON-COMPLIANT
6. TREATMENT PLAN FOR PRIMARY DIAGNOSIS
(Medical, mental health, surgical procedures or therapies planned or recommended over the next three years.
For cancer patients, include date of diagnosis, types of treatment, responses to treatment, if treatment is active and if treatment is completed.)
7. SECONDARY DIAGNOSIS 1
a. DIAGNOSIS
b. CODE
.
8. MEDICATION HISTORY
(Associated with secondary diagnosis)
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
9. HOSPITAL SUPPORT FOR THE LAST 12 MONTHS
(Associated with secondary diagnosis)
a. NUMBER OF ER VISITS/URGENT
d. NUMBER OF OUTPATIENT
b. NUMBER OF HOSPITALIZATIONS
c. NUMBER OF ICU ADMISSIONS
CARE VISITS
VISITS
10. PROGNOSIS
(X one)
EXCELLENT
GOOD
FAIR
POOR
GUARDED
UNSTABLE
NON-COMPLIANT
11. TREATMENT PLAN FOR SECONDARY DIAGNOSIS
(Medical, mental health, surgical procedures or therapies planned or recommended over the next three
years. For cancer patients, include date of diagnosis, types of treatment, responses to treatment, if treatment is active and if treatment is completed.)
DD FORM 2792, AUG 2014
Page 4 of 11 Pages

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