Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 8

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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
(Continued)
PART B - REQUIRED MEDICAL SPECIALTIES
22. MINIMUM HEALTH CARE REQUIRED
INDICATE FREQUENCY OF CARE: A - ANNUALLY B - BIANNUALLY (Twice a year)
Q - QUARTERLY M - MONTHLY BI - BI-MONTHLY W - WEEKLY
(1)
(2)
(1)
(2)
CARE PROVIDER
FREQUENCY
CARE PROVIDER
FREQUENCY
(X as appropriate)
(See above)
(X as appropriate)
(See above)
C01
a. ALLERGIST/IMMUNOLOGIST
C57
hh. ORAL SURGEON
C99
b. AUDIOLOGIST
C47
ii.
ORTHOPEDIC SURGEON - ADULT
C52
c. BEHAVIOR ANALYST
C48
jj.
ORTHOPEDIC SURGEON - PEDIATRIC
C42
d. CARDIAC/THORACIC SURGEON
C56
kk. OTORHINOLARYNGOLOGIST
C02
e. CARDIOLOGIST - ADULT
C77
ll.
PAIN CLINIC
C03
f.
CARDIOLOGIST - PEDIATRIC
C72
mm. PEDIATRIC NURSE PRACTITIONER
C70
g. CLEFT PALATE TEAM - PEDIATRIC
C30
nn. PEDIATRICIAN
C05
h. DERMATOLOGIST
C49
oo. PEDIATRIC SURGEON
C06
i.
DEVELOPMENTAL PEDIATRICIAN
C32
pp. PHYSIATRIST (Physical Rehabilitation)
C53
j.
DIALYSIS TEAM
C58
qq. PHYSICAL THERAPIST
C07
k. DIETARY/NUTRITION SPECIALIST
C50
rr.
PLASTIC SURGEON - ADULT
C08
l.
ENDOCRINOLOGIST - ADULT
C71
ss. PLASTIC SURGEON - PEDIATRIC
C09
m. ENDOCRINOLOGIST - PEDIATRIC
C99
tt.
PODIATRIST
C10
n. FAMILY PRACTITIONER
C35
uu. PSYCHIATRIST - ADULT
C11
o. GASTROENTEROLOGIST - ADULT
C36
vv. PSYCHIATRIST - PEDIATRIC
C12
p. GASTROENTEROLOGIST - PEDIATRIC
C72
ww. PSYCHIATRIST NURSE PRACTITIONER
C43
q. GENERAL SURGEON
C37
xx.
PSYCHOLOGIST - ADULT
C14
r. GENETICS
C38
yy.
PSYCHOLOGIST - PEDIATRIC
C15
s.
GYNECOLOGIST
C33
zz.
PULMONOLOGIST - ADULT
C99
t.
GYNECOLOGIST/ONCOLOGIST
C76
aaa. PULMONOLOGIST - PEDIATRIC
C17
u.
HEMATOLOGIST/ONCOLOGIST - ADULT
C99
bbb. RADIATION ONCOLOGIST
C18
v. HEMATOLOGIST/ONCOLOGIST - PEDIATRIC
C60
ccc. RESPIRATORY THERAPIST
C75
w. INFECTIOUS DISEASE
C39
ddd. RHEUMATOLOGIST - ADULT
C20
x. INTERNIST
C40
eee. RHEUMATOLOGIST - PEDIATRIC
C21
y. NEPHROLOGIST - ADULT
C61
fff.
SOCIAL WORKER
C22
z. NEPHROLOGIST - PEDIATRIC
C62
ggg. SPEECH AND LANGUAGE PATHOLOGIST
C23
aa. NEUROLOGIST - ADULT
C41
hhh. TRANSPLANT TEAM
C24
bb. NEUROLOGIST - PEDIATRIC
C51
iii.
UROLOGIST - ADULT
C44
cc. NEUROSURGEON
C78
jjj.
UROLOGIST - PEDIATRIC
C54
dd. OCCUPATIONAL THERAPIST - ADULT
C99
kkk. VASCULAR SURGEON
C55
ee. OCCUPATIONAL THERAPIST - PEDIATRIC
C99
lll.
OTHER (Describe)
C26
ff. OPHTHALMOLOGIST - ADULT
C27
gg. OPHTHALMOLOGIST - PEDIATRIC
DD FORM 2792, AUG 2014
Page 6 of 11 Pages

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