Form DD-2792 Exceptional Family Member Medical History

INSTRUCTIONS FOR COMPLETING DD FORM 2792,
FAMILY MEMBER MEDICAL SUMMARY
GENERAL.

Items 11.a. - h. Mark (X) all services being provided to the family member.

The DD Form 2792 and attached addenda are completed to identify a
family member with special medical needs.
The addenda to the medical summary are completed only if noted in
Item 10 of the Demographics/Certification section (p.3).
The Exceptional Family Member Program (EFMP)/ Special Needs
Identification and Clearance (SNIAC) Screening Coordinator and the
Parent/Guardian or Person of Majority Age sign Items 6.b and 13.b only
after all addenda have been completed and the form reviewed for
completeness and accuracy.

Item 12.a. Additional Family Member. Answer Yes if there is any member
of the family, not including this patient, who has been identified as having
special needs.

AUTHORIZATION FOR DISCLOSURE (Page 1).
Health Insurance Portability and Accountability Act (HIPAA)
Requirement.
Each adult family member must sign for the release of his/her own
medical information. The sponsor or spouse cannot authorize the release
of information for those dependent family members who have reached the
age of majority. Please consult with your military treatment facility (MTF)
or dental treatment facility (DTF) privacy/HIPAA coordinator about
questions regarding authorizations for disclosure.

Item 12.b. Indicate the number of other family members who have been
identified as an EFM. Do not include the individual named in this
summary in the count of family members.
Items 13.a. - e. EFMP/SNIAC/Screening Coordinator or Advisor name,
signature, date, facility address, telephone number. Self-explanatory.
Coordinator must ensure that all forms are complete and attached
before signing.
Item 13.f. This area is reserved for Service-specific guidance to validate the
form.
MEDICAL SUMMARY beginning on page 4 must be completed by a
qualified medical professional.
Sponsor, spouse, or family member of majority age must sign release
authorization on page 4 before this summary is completed.

DEMOGRAPHICS/CERTIFICATION (Page 2).
Item 1.a. - c. Pertains to children under 6 years of age. Self-explanatory.
Items 1. Self-explanatory.

D R A F T

Item 2.a. Family Member (FM). Name of family member described in
subsequent pages.
Item 2.b. Self-explanatory.
Item 2.c. Applies to Military medical beneficiary only. The Family Member
Prefix is assigned when the family member is enrolled in DEERS.

Items 2.a. - d. Temporary Conditions. Self-explanatory.
Item 3.a. Diagnosis. Enter the diagnosis(es), one per line. With the
exception of asthma, cancer or mental health, identify all diagnoses that
have been active within the last year. For asthma, cancer or mental health,
identify all diagnoses active within the last 5 years.
Item 3.b. ICD or DSM. Enter ICD-9-CM or DSM IV designations.
REQUIRED.

Items 2.d. - i. Self-explanatory.
Items 3.a. - j. All items refer to the sponsor. Self- explanatory.
Item 4.a. Answer Yes if both spouses are on active duty; otherwise
answer No.
If Yes, complete Items 4.b. - e. All items refer to the active duty spouse.
Self-explanatory.
IItem 5.a. - d. If Yes, enter Social Security Number, name of sponsor and
branch of Service. Military only.
Item 6.a. - c. Parent/Guardian or Person of Majority Age. Parent/guardian
or person of majority age certifies that the information contained in the DD
2792 is correct. Individual must ensure that all forms are completed
and attached before signing.
Item 7. Purpose for Completing the Form (X one). Initial Screening
Enrollment - Review of medical history for the family member noted for
the purpose of determining eligibility for EFMP. Request for government
sponsored travel and/or command sponsorship review of projected
location(s). Update to previous evaluation for the family member.
Qualifies for a change in EFMP status. Used to disenroll an EFMP when
he/she no longer has the medical condition that requires enrollment, or
when the EFM no longer qualifies as a dependent.

Item 3.c. Medications and Therapies. Self-explanatory. Additional
information may be included in item 11 if more space is required.
Item 3.d. Enter per diagnosis the number of outpatient visits, ER visits,
hospitalizations and ICU admissions for the last 12 months.
Item 4. Prognosis. Self-explanatory. Additional information may be
included in item 11 if more space is required.
Item 5. Treatment Plan. Self-explanatory. Additional information may be
included in item 11 if more space is required.
Item 6. Cancer. Self-explanatory.
Item 7. Minimum Health Care Specialty. Codes in the first column are used
by Army coding teams only. In column 1, indicate with an X those
specialists essential (required) to meet the needs of the patient. For
example, if a developmental pediatrician is a child's primary care provided,
but a pediatrician can meet the needs, do not mark developmental
pediatrician. In column 2, indicate frequency of care. Enter A - Annually; B
- Biannually; Q - Quarterly; M - Monthly; Bi - Bimonthly; W - Weekly.
Item 8 - Artificial Openings. Self-explanatory.
Item 9 - Environmental/Architectural Considerations. Self-explanatory.

Item 8. Indicate status of medical condition.
Item 9.a. If yes, complete b. - c.
Item 10. Required Addenda. This addendum is completed only if
applicable to the patient described. Indicate in block 1 Yes or No. If Yes,
proceed with addendum and sign. If No, do not complete addendum.
Signature of Qualified Medical Provider is required. Each Military
Service may additionally indicate need to complete addenda in item 10,
page 3, when determining the purpose of completing this form and may
be completed by a different provider than pages 4 - 7, if necessary.

DD FORM 2792 INSTRUCTIONS, 20091105 DRAFT

Item 10. Adaptive Equipment/Special Medical Equipment.
Self-explanatory.
Item 11. Comments. Enter any additional information that would assist in
determining necessary treatment.
Item 12.a. - f. Provider Information. Official Stamp or printed name and
signature of the provider completing this summary, and the date the
summary was signed. Self-explanatory.

Page i
Adobe Professional 8.0

INSTRUCTIONS FOR COMPLETING DD FORM 2792 (Continued)
ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE SUMMARY
(p.8). To be completed by a qualified medical professional.
This addendum is completed only if applicable to the patient described.
Indicate in block 1 Yes or No. If Yes, proceed with addendum and sign. If
No, do not complete addendum . Signature of Qualified Medical
Provider is required. Each military Service may additionally indicate
need to complete addenda in item 10, page 3, when determining the
purpose of completing this form and may be completed by a different
provider than pages 4 - 7, if necessary.
Item 1. Self-explanatory.

ADDENDUM 3 - AUTISM SPECTRUM DISORDERS AND
SIGNIFICANT DEVELOPMENTAL DELAYS (p.11). To be
completed by a qualified medical professional.
This addendum is completed only if applicable to the patient
described. Indicate in block 1 Yes or No. If Yes, proceed with
addendum and sign. If No, do not complete addendum .
Signature of Qualified Medical Provider is required. Each
military Service may additionally indicate need to complete
addenda in item 10, page 3, when determining the purpose of
completing this form and may be completed by a different
provider than pages 4 - 7, if necessary.

Items 2.a.- d. Self-explanatory.
Item 1. Self-explanatory.

Items 3.a.- k. Self-explanatory.
Items 4.a. - f. Self-explanatory.
Items 5.a. - d. Self-explanatory.

D R A F T

Items 2.a.- b. Diagnosis(es). Self-explanatory.
Items 3. Self-explanatory.

Items 6.a. - f. Provider Information. Official Stamp or printed name and
signature of the provider completing this summary, and date the summary
was signed. Self-explanatory.

Item 4. Coexisting Diagnoses. Indicate coexisting diagnosis.

ADDENDUM 2 - MENTAL HEALTH SUMMARY
(pp. 9 - 10). To be completed by a qualified clinical provider.

Item 6. Current Interventions/Therapies. Indicate current
interventions/therapies, if known.

This addendum is completed only if applicable to the patient described.
Indicate in block 1 Yes or No. If Yes, proceed with addendum and sign. If
No, do not complete addendum . Signature of Qualified Medical
Provider is required. Each military Service may additionally indicate
need to complete addenda in item 10, page 3, when determining the
purpose of completing this form and may be completed by a different
provider than pages 4 - 7, if necessary.
Item 1. Self-explanatory.
Items 2.a. - d. Self-explanatory. Item 2.b. ICD or DSM is REQUIRED.
Item 3. Self-explanatory.

Item 5. Current Medications. Self-explanatory.

Item 7. Communication. Self-explanatory.
Item 8. Other Interventions/Therapies Used by the Family.
Specify any alternate or complementary therapies used.
Item 9. Behavior. Answer yes if the child exhibits high risk or
dangerous behaviors. Additional information may be included in
item 14 if more space is required.
Item 10. Cognitive Ability. Indicate appropriate intelligence
quotient (IQ), if known.

Item 4.a. - i. History. Self-explanatory.

Item 11. Education. Self-explanatory.

Item 5. Prognosis. Self-explanatory. Additional information may be
included in Item 9 if more space is required.

Item 12. Required Medical Services. Self-explanatory.

Item 6. Treatment Plan. Self-explanatory. Additional information may be
included in Item 9 if more space is required.

Item 13. Respite Care Received. Provide the number of hours
per month, and the source, e.g., EFMP Respite Care Program,
ECHO or Medicaid.

Item 7. Expected treatment needs within the next year. Mark only one
box considering all diagnoses. Self-explanatory.

Item 14. General Comments. Self-explanatory.

Item 8. Required Providers and Frequency of Visits. Mark all providers
who are required to implement the treatment plan..

Item 15. Provider Information. Official Stamp or printed name
and signature of the provider completing this summary and date
the summary was signed. Self-explanatory.

Item 9. Comments. Enter any additional information that would assist in
determining necessary treatment.
Items 10.a - f. Provider Information. Official Stamp or printed name and
signature of the provider completing this summary, and date the summary
was signed. Self-explanatory.

DD FORM 2792 INSTRUCTIONS (BACK), 20091105 DRAFT

Page ii

FAMILY MEMBER MEDICAL SUMMARY
(To be completed by service member, adult family member, or civilian employee.)
(Read Instructions before completing this form.)

OMB No. 0704-0411
OMB approval expires

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, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (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 USC 3013, 5013, and 8013; 20 USC 921 - 932; and EO 9397.
PRINCIPAL PURPOSE(S): Information will only be used by personnel of the Department of Defense and Military Departments to evaluate and document
the medical needs of family members. This information will enable: (1) Military assignment personnel to match the needs of family members against the
availability of medical services and to engage in case management after assessment is made; (2) Civilian personnel offices to determine the availability of
medical services to meet the medical needs of family members of DoD and Military Department civilian employees; and (3) Managed Care Support
Contractor to support your application for further entitlement, i.e., the Extended Care Health Option (ECHO); and other Service-specific programs that
require registration in the Exceptional Family Member Program (EFMP).
ROUTINE USE(S): None.

D R A F T

DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment; failure to respond will preclude the successful processing of an
application for travel/command sponsorship.
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.

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 make 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.
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/Special Needs 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.
e. Failure to release this information or any subsequent revocation may result in ineligibility for community based services, and/or 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.
NAME OF PATIENT

SIGNATURE OF PATIENT/PARENT/GUARDIAN

RELATIONSHIP TO PATIENT (If

DATE (YYYYMMDD)

applicable)

DD FORM 2792, 20091105 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 11 Pages

DEMOGRAPHICS/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

SUMMARIZE MEDICAL INFORMATION FOR
OFFICIAL USES
REQUEST FOR GOVERNMENT SPONSORED
TRAVEL AND/OR COMMAND SPONSORSHIP

NO LONGER HAVE PREVIOUSLY IDENTIFIED
CONDITION

FAMILY MEMBER DECEASED*

NO LONGER QUALIFIES AS A DEPENDENT*

DIVORCE/CHANGE IN CUSTODY*

(*Maintain documentation to verify change in status - do not update medical information.)

OTHER (Explain):

D R A F T
2.a. FAMILY MEMBER/PATIENT NAME (Last, First, Middle

b. SPONSOR NAME (Last, First, Middle Initial)

Initial)

e. FAMILY MEMBER GENDER (X)
MALE

c. FAMILY MEMBER
PREFIX (FMP)

d. SPONSOR SSN

f. FAMILY MEMBER DATE OF BIRTH (YYYYMMDD) g. CURRENT FAMILY MEMBER MAILING ADDRESS
(Street, Apartment Number, City, State, ZIP Code, APO/FPO)

FEMALE

h. HOME TELEPHONE NUMBER
(Include Area Code/Country Code)

i. FAMILY HOME E-MAIL ADDRESS

3.a. SPONSOR RANK OR GRADE

b. DESIGNATION/NEC/MOS/AFSC (Military only)

d. BRANCH OF SERVICE (Military only)
ARMY
NAVY

c. INSTALLATION OF SPONSOR'S CURRENT ASSIGNMENT

e. STATUS (X one)

AIR FORCE

REGULAR ACTIVE SERVICE MEMBER

RESERVIST

MARINE CORPS

ACTIVE GUARD RESERVE PROGRAM
(AGR)

NATIONAL GUARD

CIVILIAN

f. SPONSOR'S CURRENT UNIT MAILING ADDRESS

h. DUTY TELEPHONE NUMBER
(Include Area Code/CountryCode)

g. SPONSOR'S OFFICIAL E-MAIL ADDRESS

i. MOBILE NUMBER
(Include Area Code/Country Code)

j. DOES FAMILY MEMBER RESIDE WITH SPONSOR (X one. If No, explain.)
YES
NO

4.a. ARE BOTH SPOUSES ON ACTIVE DUTY? (Military only) (X one. If Yes, complete 4.b. - e. below)
YES

b. ACTIVE DUTY SPOUSE'S NAME (Last, First, Middle Initial)

c. BRANCH OF SERVICE

d. RANK/RATE

e. SPOUSE SSN

NO

5.a. IS FAMILY MEMBER ENROLLED IN DEERS UNDER A DIFFERENT SPONSOR'S NAME? (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. CERTIFICATION.
DO NOT CERTIFY BEFORE COMPLETING ENTIRE FORM AND ADDENDA.
By signing below, we certify that the information submitted on this DD Form 2792 (Medical Summary and the addenda checked below) is complete
and accurate.
PARENT/GUARDIAN OR PERSON OF MAJORITY AGE:
a. PRINTED NAME

DD FORM 2792, 20091105 DRAFT

b. SIGNATURE

c. DATE (YYYYMMDD)

Page 2 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

FOR ADMINISTRATIVE USE ONLY
7. REQUIRED ACTIONS (X one)
FIRST REVIEW OF MEDICAL HISTORY FOR THE FAMILY
MEMBER

QUALIFIES FOR CHANGE IN EFMP STATUS:

REQUEST FOR GOVERNMENT SPONSORED TRAVEL
AND/OR COMMAND SPONSORSHIP - REVIEW
PROJECTED LOCATION(S)

FAMILY MEMBER NO LONGER HAS PREVIOUSLY
IDENTIFIED CONDITION

FAMILY MEMBER
DECEASED*

UPDATE TO A PREVIOUS EVALUATION FOR THE FAMILY
MEMBER

FAMILY MEMBER NO LONGER QUALIFIES AS A
DEPENDENT*

DIVORCE/CHANGE IN
CUSTODY*

OTHER (e.g., Extended Care Health Option Eligibility):

(*Maintain documentation to verify change in status - do not update medical information.)

D R A F T
8. SUMMARY (X one)
ONGOING MEDICAL CONDITIONS

TEMPORARY MEDICAL CONDITIONS

BOTH

9.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)
c. CASE MANAGER CONTACT INFORMATION
(1) NAME (Last, First, Middle Initial)

MTF

TRICARE

(2) TELEPHONE NUMBER
(Include Area Code/Country Code)

CIVILIAN

(3) ADDRESS (Include ZIP Code or APO/FPO)

10. REQUIRED ADDENDA. Complete Item 1 on Addendum 1 (page 8) and item 1 on Addendum 2 (page 9) and item 1 on Addendum 3
(page 11) AND X box below if:
ASTHMA ADDENDUM 1 IS REQUIRED AND

ATTACHED

MENTAL HEALTH SUMMARY ADDENDUM 2 IS REQUIRED AND

ATTACHED

AUTISM SPECTRUM DISORDER/DEVELOPMENTAL DELAY ADDENDUM 3 IS REQUIRED AND

ATTACHED

11. SPECIAL ASSIGNMENT CONSIDERATIONS (X all that apply)
a. POSSIBLE SPECIAL EDUCATION/EARLY INTERVENTION
(If marked, DD Form 2792-1 must be completed)

e. RECEIVING STATE MEDICAID/MEDICARE WAIVER SERVICES

b. RECEIVING TRICARE EXTENDED CARE HEALTH OPTION
(ECHO) BENEFITS

f. RECEIVING VOCATIONAL REHABILITATION SERVICES

c. RECEIVING SUPPLEMENTAL SOCIAL SECURITY INCOME
(SSI) FROM THE SOCIAL SECURITY ADMINISTRATION

g. RECEIVING SPECIAL CHILD CARE ACCOMMODATIONS

d. RECEIVING SOCIAL SECURITY DISABILITY INSURANCE
(SSDI) FROM THE SOCIAL SECURITY ADMINISTRATION

h. OTHER (Specify)

12.a. ARE THERE OTHER EFMP MEMBERS IN THE FAMILY (Not including this family member)?
YES

NO

b. IF YES, HOW MANY?

13. ADMINISTRATIVE CERTIFICATION
a. PRINTED NAME (Last, First, Middle Initial)

b. TITLE

e. FACILITY ADDRESS (Include ZIP Code or APO/FPO)

DD FORM 2792, 20091105 DRAFT

c. SIGNATURE

f. TELEPHONE NUMBER
(Include area code/Country Code)

d. DATE (YYYYMMDD)

g. OFFICIAL STAMP

Page 3 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

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)
1. FOR CHILDREN UNDER AGE 6 ONLY
a. IF PATIENT IS LESS THAN 12 MONTHS OLD, WAS IT A PREMATURE BIRTH? (X one)
YES

b. DATE OF LAST WELL-CHILD EXAMINATION (YYYYMMDD)

NO

c. WERE ALL DEVELOPMENTAL MILESTONES WITHIN NORMAL LIMITS? (X one. If No, please explain.)
YES

NO

2. TEMPORARY CONDITIONS THAT MAY IMPACT TRAVEL CONSIDERATIONS IN THE NEXT YEAR
a.
DIAGNOSIS

c.
MEDICATIONS AND SPECIAL THERAPIES

b.
ICD OR DSM: REQUIRED

d. TIME FRAME (Explain anticipated duration of temporary condition and identify any limitations for activities of daily living and travel considerations.)

D R A F T
3. DIAGNOSIS(ES)

Please complete as accurately as possible using ICD-9-CM or DSM IV Use item 11 (Comments) if more space is needed.

a.
ACTIVE DIAGNOSIS WITHIN LAST YEAR (If
Asthma, Cancer or Mental Health within last 5
years)

b.
ICD OR DSM
REQUIRED

c.
MEDICATIONS AND
SPECIAL THERAPIES

d.
COMPLETE FOR
THE LAST 12 MONTHS:

If Asthma or RAD is noted, also complete Asthma Addendum 1.
If Mental Health is noted, also complete Mental Health Addendum 2.
If Autism Spectrum Disorder(ASD)/Developmental Delay (DD) is noted, also complete Addendum 3.
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS

DD FORM 2792, 20091105 DRAFT

Page 4 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

4. PROGNOSIS FOR EACH ACTIVE DIAGNOSIS IDENTIFIED IN PART A, ITEM 3 (Include expected length of treatment, required participation of family
members, and if treatment is ongoing)

5. TREATMENT PLAN FOR EACH ACTIVE DIAGNOSIS (Medical, mental health, surgical procedures or therapies planned over the next three years)

D R A F T

6. CANCER, ADDITIONAL INFORMATION (If not addressed in Items 3, 4, and 5) (Indicate date of diagnosis, types of treatment, responses to treatment, if
treatment is active and if treatment completed.)
IF TREATMENT COMPLETED, DATE (YYYYMMDD)

DD FORM 2792, 20091105 DRAFT

Page 5 of 11 Pages

SPONSOR NAME

FAMILY MEMBER/PATIENT NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

MEDICAL SUMMARY (Continued): To be completed by a Qualified Medical Professional

D R A F T
PART B - REQUIRED CARE

7. MINIMUM HEALTH CARE SPECIALTY REQUIRED FOR CARE
INDICATE THE FREQUENCY OF CARE:

A - ANNUALLY

(1) CARE PROVIDER
(X as appropriate)

B - BIANNUALLY (Twice a year)
(2)
FREQUENCY
(See above)

Q - QUARTERLY

M - MONTHLY

W - WEEKLY
(2)
FREQUENCY
(See above)

(1) CARE PROVIDER
(X as appropriate)

C01

a. ALLERGIST/IMMUNOLOGIST

C56

gg. OTORHINOLARYNGOLOGIST

C52

b. AUDIOLOGIST

C47

hh. ORTHOPEDIC SURGEON - ADULT

C42

c. CARDIAC/THORACIC SURGEON

C48

ii.

ORTHOPEDIC SURGEON - PEDIATRIC

C02

d. CARDIOLOGIST - ADULT

C57

jj.

PAIN CLINIC

C03

e. CARDIOLOGIST - PEDIATRIC

C72

kk.

PEDIATRIC NURSE PRACTITIONER

C70

f.

C30

ll.

PEDIATRICIAN

C05

g. DERMATOLOGIST

C49

mm. PEDIATRIC SURGEON

C06

h. DEVELOPMENTAL PEDIATRICIAN

C32

nn. PHYSIATRIST (Physical Rehabilitation)

C53

i.

DIALYSIS TEAM

C58

oo. PHYSICAL THERAPIST

C07

j.

DIETARY/NUTRITION SPECIALIST

C50

pp. PLASTIC SURGEON - ADULT

C08

k.

ENDOCRINOLOGIST - ADULT

C71

qq. PLASTIC SURGEON - PEDIATRIC

C09

l.

ENDOCRINOLOGIST - PEDIATRIC

C35

rr.

PSYCHIATRIST - ADULT

C10

m. FAMILY PRACTITIONER

C36

ss.

PSYCHIATRIST - PEDIATRIC

C11

n. GASTROENTEROLOGIST - ADULT

C72

tt.

PSYCHIATRIST NURSE PRACTITIONER

C12

o. GASTROENTEROLOGIST - PEDIATRIC

C37

uu. PSYCHOLOGIST - ADULT

C43

p. GENERAL SURGEON

C38

vv.

C14

q. GENETICS

C33

ww. PULMONOLOGIST - ADULT

C15

r.

GYNECOLOGIST

C76

xx.

PULMONOLOGIST - PEDIATRIC

C17

s.

HEMATOLOGIST/ONCOLOGIST - ADULT

C60

yy.

RESPIRATORY THERAPIST

C18

t.

HEMATOLOGIST/ONCOLOGIST - PEDIATRIC

C39

zz.

RHEUMATOLOGIST - ADULT

C75

u. INFECTIOUS DISEASE

C40

aaa. RHEUMATOLOGIST - PEDIATRIC

C20

v. INTERNIST

C61

bbb. SOCIAL WORKER

C21

w. NEPHROLOGIST - ADULT

C62

ccc. SPEECH AND LANGUAGE PATHOLOGIST

C22

x. NEPHROLOGIST - PEDIATRIC

C41

ddd. TRANSPLANT TEAM

C23

y. NEUROLOGIST - ADULT

C51

eee. UROLOGIST - ADULT

C24

z. NEUROLOGIST - PEDIATRIC

C78

fff.

C44

aa. NEUROSURGEON

C99

ggg. OTHER (Describe)

C54

bb. OCCUPATIONAL THERAPIST - ADULT

C55

cc. OCCUPATIONAL THERAPIST - PEDIATRIC

C26

dd. OPHTHALMOLOGIST - ADULT

C27

ee. OPHTHALMOLOGIST - PEDIATRIC

C57

ff. ORAL SURGEON

CLEFT PALATE TEAM - PEDIATRIC

DD FORM 2792, 20091105 DRAFT

PSYCHOLOGIST - PEDIATRIC

UROLOGIST - PEDIATRIC

Page 6 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

MEDICAL SUMMARY (Continued): To be completed by a Qualified Medical Professional
8. ARTIFICIAL OPENINGS/PROSTHETICS (X all that apply)
YES

IF YES:

NO

F01 - GASTROSTOMY

F05 - COLOSTOMY

F02 - TRACHEOSTOMY

F06 - ILEOSTOMY

F03 - CSF SHUNT

F07 - OTHER UNSPECIFIED PROSTHETICS (Specify)

F04 - CYSTOSTOMY

F99 - OTHER UNSPECIFIED OPENING (Specify)

9. ENVIRONMENTAL/ARCHITECTURAL CONSIDERATIONS
R01 - LIMITED STEPS (If Yes, please explain)

R03 - AIR CONDITIONING

R02 - COMPLETE WHEELCHAIR ACCESSIBILITY

R03a - TEMPERATURE CONTROL

R04 - SINGLE STORY/LEVEL HOUSE

R03b - HEPA FILTER

R05 - CARPET PROHIBITED

R03c - POLLEN CONTROL

R99 - OTHER (Specify)

R03d - AIR FILTERING

EXPLANATION OF SPECIAL CONSIDERATIONS:

D R A F T
10. ADAPTIVE EQUIPMENT/SPECIAL MEDICAL EQUIPMENT
L03 - APNEA HOME MONITOR

L07 - SPLINTS, BRACES, ORTHOTICS

L21 - CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) THERAPY

L08 - WHEELCHAIR

L20 - HOME DIALYSIS MACHINE

L12 - HOME OXYGEN THERAPY

L13 - HOME NEBULIZER

L14 - HOME VENTILATOR

L04 - HEARING AIDS:

MAKE:

MODEL:

L22 - INSULIN PUMP:

MAKE:

MODEL:

L23 - PACEMAKER:

MAKE:

MODEL:

L99 - OTHER (Specify)
EXPLANATION OF SPECIAL CONSIDERATIONS:

11. COMMENTS (Enter additional information to describe this individual's medical needs.)

PART C - PROVIDER INFORMATION
12.a. PROVIDER PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code/Country Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)

(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792, 20091105 DRAFT

Page 7 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE SUMMARY: To be completed by a Qualified Medical Professional
1. PATIENT HAS BEEN EVALUATED OR TREATED FOR ASTHMA WITHIN THE PAST 5 YEARS.
NO

YES

IF YES, CONTINUE COMPLETION OF ASTHMA ADDENDUM ITEMS 2 - 6.

2. MEDICATION HISTORY
a. MEDICATION

b. DOSAGE

c. FREQUENCY

d. APPROXIMATE DATE
MEDICATION LAST USED

D R A F T

3. HISTORY ASSOCIATED WITH ASTHMA ATTACKS (X as applicable)
YES

NO
a. ARE THERE ANY TRIGGERS FOR THE FAMILY MEMBER'S ASTHMA ATTACKS (stress, environment, exercise)?
b. DOES THE FAMILY MEMBER ROUTINELY (greater than 10 days per month/four months per year) USE INHALED ANTI-INFLAMMATORY
AGENTS AND/OR BRONCHODILATORS?
c. HAS THE FAMILY MEMBER TAKEN ORAL STEROIDS DURING THE PAST YEAR (prednisone, prednisolone)?
IF YES, NUMBER OF DAYS IN PAST YEAR:
d. HAS THE FAMILY MEMBER EVER EXPERIENCED UNCONSCIOUSNESS OR SEIZURES ASSOCIATED WITH ASTHMA ATTACKS?
e. HAS THE FAMILY MEMBER REQUIRED AN URGENT VISIT TO THE ER OR CLINIC FOR ACUTE ASTHMA DURING THE PAST YEAR?
IF "YES', INDICATE THE NUMBER OF VISITS IN THE PAST YEAR:
f. HAS THE FAMILY MEMBER BEEN HOSPITALIZED FOR PULMONARY DISEASE (pneumonia, bronchitis, bronchiolitis, croup, RSV) DURING
THE PAST YEAR? IF "YES', INDICATE THE DATE(S) OF HOSPITALIZATION (YYYYMMDD):
g. DOES THE FAMILY MEMBER HAVE A HISTORY OF ONE OR MORE HOSPITALIZATIONS FOR ASTHMA RELATED CONDITIONS WITHIN
THE PAST 5 YEARS? IF "YES', HOW MANY?
INDICATE DATE OF LAST ADMISSION (YYYYMMDD):
h. HAS THE FAMILY MEMBER REQUIRED MECHANICAL VENTILATION (Intubation/use of respirator) DURING THE PAST 3 YEARS?
i. DOES THE FAMILY MEMBER HAVE A HISTORY OF INTENSIVE CARE ADMISSIONS?

j. HOW MANY DAYS HAS THE FAMILY MEMBER MISSED SCHOOL/WORK/PLAY DUE TO ASTHMA-RELATED PROBLEMS (including visits to physicians)
DURING THE PAST YEAR?
k. HOW OFTEN DOES THE FAMILLY MEMBER USE HIS/HER RESCUE INHALER OR NEBULIZER MEDICATION (such as Albuterol or Levalbuterol) FOR
INCREASED OR ACUTE SYMPTOMS?

4. DISRUPTION OF ACTIVITY. How often does asthma disrupt the following activities? (X as applicable)
(1) ACTIVITY

(2) NEVER A
PROBLEM

(3) 2 TIMES A
(4) 3 - 7
(5) 8 - 10 TIMES (6) AT LEAST
YEAR OR LESS TIMES A YEAR
A YEAR
MONTHLY

(7) AT LEAST
WEEKLY

(8) ALMOST
DAILY

a. SLEEP
b. QUIET ACTIVITY
c. SOCIALIZING WITH FRIENDS
d. SCHOOL OR WORK ATTENDANCE
e. OUTDOOR ACTIVITIES
f. VIGOROUS/PLAY ACTIVITIES

5. SEVERITY LEVEL. What is the family member's severity level based on the clinical picture? (Select one level of severity.
Definitions are examples of severity. Pulmonary function tests are required only if clinically indicated.)
a. INTERMITTENT ASTHMA. Intermittent symptoms < 1 time per week. Brief exacerbations (from a few hours to a few days). Nighttime asthma
symptoms < 2 times a month. Asymptomatic and normal lung function between exacerbations. PEF or FEV1 > 80% predicted; variability <20%.
b. MILD PERSISTENT ASTHMA. Symptoms > 2 times a week but < 1 time per day. Exacerbations may affect sleep and activity. Nighttime asthma
symptoms > 2 times a month. PEF or FEV1 > 80% predicted; variability 20 - 30%.
c. MODERATE PERSISTENT. Symptoms daily. Exacerbations affect sleep and activity. Nighttime asthma > 1 time a week. Daily use of inhaled
short-acting B2 agonist. PEF or FEV1 > 60% and 80% predicted; variability > 30%.
d. SEVERE PERSISTENT. Continuous symptoms. Frequent exacerbations. Frequent nighttime asthma symptoms. Physical activities limited by asthma
symptoms. PEF or FEV1 < 60% predicted; variability > 30%.

6.a. PROVIDER PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code/Country Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)

(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792 (ADDENDUM 1), 20091105 DRAFT

Page 8 of 11 Pages

FAMILY MEMBER/PATIENT NAME

SPONSOR NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

ADDENDUM 2 - MENTAL HEALTH SUMMARY: To be Completed by a Qualified Clinical Provider
1. PATIENT HAS CURRENT OR PAST (within the last 5 years) HISTORY OF MENTAL HEALTH DIAGNOSIS (To include attention deficit disorders)
NO

YES

IF YES, CONTINUE WITH COMPLETION OF MENTAL HEALTH ADDENDUM.

2. DIAGNOSIS(ES) Please complete as accurately as possible using ICD-9-CM or DSM IV.
a.
DIAGNOSIS

b.
ICD OR DSM
REQUIRED

c.
AGE AT
DIAGNOSIS

d.
COMPLETE FOR THE LAST 5 YEARS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF HOSPITALIZATIONS
(3) NUMBER OF RESIDENTIAL TREATMENT ADMISSIONS
DATE OF LAST ADMISSION:
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF HOSPITALIZATIONS
(3) NUMBER OF RESIDENTIAL TREATMENT ADMISSIONS
DATE OF LAST ADMISSION:
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF HOSPITALIZATIONS
(3) NUMBER OF RESIDENTIAL TREATMENT ADMISSIONS
DATE OF LAST ADMISSION:
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF HOSPITALIZATIONS
(3) NUMBER OF RESIDENTIAL TREATMENT ADMISSIONS
DATE OF LAST ADMISSION:

3. MEDICATION HISTORY RELATED TO THE DIAGNOSIS LISTED ABOVE; THERAPIES RECEIVED OR RECOMMENDED
(Including frequency of medication and therapy, and their effectiveness)

D R A F T
4. HISTORY
YES

NO

WITHIN THE LAST 5 YEARS, HAS THE PATIENT HAD:

i. COMMENTS

a. HISTORY OF SUICIDAL GESTURES/ATTEMPTS?
b. HISTORY OF SUBSTANCE ABUSE?
c. HISTORY OF ADDICTIVE BEHAVIORS?
d. HISTORY OF EATING DISORDERS?
e. HISTORY OF OTHER COMPULSIVE BEHAVIORS?
f. HISTORY OF PROBLEMS WITH LEGAL AUTHORITY? (If Yes, specify)

g. HISTORY OF PSYCHOTIC EPISODES?
h. HISTORY OF SERVICES RECEIVED FOR ALLEGATIONS OF FAMILY
MALTREATMENT? (If Yes, and services are delivered by Family Advocacy,
note case determination.)

DD FORM 2792 (ADDENDUM 2), 20091105 DRAFT

Page 9 of 11 Pages

SPONSOR NAME

FAMILY MEMBER/PATIENT NAME

FAMILY MEMBER PREFIX

SPONSOR SSN

ADDENDUM 2 - MENTAL HEALTH SUMMARY (Continued): To be Completed by a Qualified Clinical Provider
5. PROGNOSIS (Include past compliance with treatment programs, expected length of treatment, required participation of family members, and if
treatment is ongoing.)

6. TREATMENT PLAN (Medical, mental health, surgical procedures or therapies related to the patient's mental health condition planned over the next three years)

D R A F T
7. TREATMENT NEEDS WITHIN THE NEXT YEAR (Consider increased stressors of residing in new environment (e.g.,stressors of family relocation, isolated posts,
deployments, foreign cultures, restricted travel, separation from nuclear family, cost of living.)

8. PROVIDERS REQUIRED TO IMPLEMENT TREATMENT PLAN AND FREQUENCY OF VISITS
PSYCHIATRIST

PSYCHOLOGIST

SOCIAL WORKER

OTHER (Specify)

WEEKLY

WEEKLY

WEEKLY

WEEKLY

BI-MONTHLY

BI-MONTHLY

BI-MONTHLY

BI-MONTHLY

MONTHLY

MONTHLY

MONTHLY

MONTHLY

QUARTERLY

QUARTERLY

QUARTERLY

QUARTERLY

ANNUALLY

ANNUALLY

ANNUALLY

ANNUALLY

9. OTHER COMMENTS (Include additional information that would assist in determining necessary treatments.)

10. PROVIDER INFORMATION (Authorization by patient included on Page 1 of this form.)
a. PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)
(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792 (ADDENDUM 2) (BACK), 20091105 DRAFT

Page 10 of 11 Pages

SPONSOR NAME

FAMILY MEMBER/PATIENT NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

ADDENDUM 3 - AUTISM SPECTRUM DISORDERS AND SIGNIFICANT DEVELOPMENTAL DELAYS
To be Completed by a Qualified Medical Professional
1. PATIENT HAS BEEN EVALUATED OR RECEIVED TREATMENT(S) FOR AUTISM SPECTRUM DISORDERS AND/OR SIGNIFICANT
DEVELOPMENTAL DELAYS (X one)
NO

YES

IF YES, CONTINUE WITH COMPLETION OF AUTISM AND SIGNIFICANT DEVELOPMENTAL DELAYS ADDENDUM 3, ITEMS 2 - 15.

3. DATE OF BIRTH (YYYYMMDD)

b. AGE WHEN DIAGNOSED

2.a. DIAGNOSIS(ES) (X and complete as applicable)
PERVASIVE
DEVELOPMENTAL DISORDER

AUTISTIC DISORDER
ASPERGER'S SYNDROME
OTHER (Specify)
c. DIAGNOSED BY:
CHILD PSYCHOLOGIST

DEVELOPMENTAL PEDIATRICIAN

OTHER PHYSICIAN

CHILD PSYCHIATRIST

MEDICAL MULTIDISCIPLINARY TEAM

SCHOOL-BASED TEAM

OTHER (Specify)

4. COEXISTING DIAGNOSES (X all that apply)
CHROMOSOMAL ABNORMALITIES

INTERMITTENT EXPLOSIVE DISORDER

OBSESSIVE COMPULSIVE DISORDER

CIRCADIAN-RHYTHM SLEEP DISORDER

MAJOR DEPRESSIVE DISORDER,
DEPRESSIVE DISORDER, NOS
SEIZURE DISORDER

ATTENTION DEFICIT/HYPERACTIVITY
GENERALIZED ANXIETY DISORDER,
DISORDER
ANXIETY DISORDER, NOS
5. CURRENT MEDICATIONS (Used to treat diagnoses on this page)

OTHER (Specify)

D R A F T

6. CURRENT INTERVENTION THERAPIES

(2)
SCHOOL
HOURS/WEEK
(If known)

(1)
TYPE

(3)
TRICARE
HOURS/WEEK
(If known)

(4)
OTHER SOURCE
HOURS/WEEK
(If known)

(5)
OTHER
(Identify)

a. SPEECH THERAPY
b. OCCUPATIONAL THERAPY
c. PHYSICAL THERAPY
d. PSYCHOLOGICAL COUNSELING
e. INTENSIVE BEHAVIORAL INTERVENTION (Includes ABA)
f. OTHER (Specify)

7. COMMUNICATION (X )
VERBAL

8. OTHER INTERVENTIONS/THERAPIES USED BY THE FAMILY (Specify)

NON-VERBAL (Uses:)

SIGNING
PICTURE EXCHANGE COMMUNICATION SYSTEM

9. BEHAVIOR: CHILD EXHIBITS HIGH RISK OR DANGEROUS BEHAVIOR

COMMUNICATION DEVICE
COMBINATION

YES

10. COGNITIVE ABILITY (X )

NO (If Yes, provide details in Item 14 below)

11. EDUCATION (X )

<50

UNKNOWN

RECEIVES EARLY INTERVENTION

ATTENDS PUBLIC SCHOOL

50 - 70

INDETERMINATE

RECEIVES SPECIAL EDUCATION

ATTENDS PRIVATE SCHOOL

ATTENDS SPECIAL PRIVATE SCHOOL

IS HOME SCHOOLED

>70

12. REQUIRED MEDICAL SERVICES (X)

13. RESPITE CARE RECEIVED

CHILD PSYCHOLOGY

CHILD NEUROLOGY

CHILD PSYCHIATRY

DEVELOPMENTAL PEDIATRICS

a. HOURS PER
MONTH

b. SOURCE

OTHER (Specify)

14. GENERAL COMMENTS (Include Functional Levels)

15. PROVIDER INFORMATION
a. PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)
(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792 (ADDENDUM 3), 20091105 DRAFT

Page 11 of 11 Pages