Highlights for the Completion of DD Form 2792

“Family Member Medical Summary”

NAVAL MEDICAL CENTER PORTSMOUTHEFMP COORDINATOR OFFICE

• DD Form 2792 must be completed for all EFMP enrollees.• DD Form 2792 (and DD Form 2792-1, if applicable) are also the forms used when

updating EFMP paperwork every three years, when the condition changes, or the EFM needs to be otherwise disenrolled.

• Turn completed package into EFMP Coordinator (NMCP and/or outlying branch clinics).

EFMP Guidance

DOD Instruction 1315.19, 20 Dec 05, Authorizing Special Needs Family Members Travel Overseas at Government Expense SECNAV Instruction 1754.5B, 14 Dec 05, Exceptional Family Member ProgramOPNAV Instruction 1754.D, 03 NOV 10, Exceptional Family Member (EFM) ProgramBUMED Instruction 1300.2A, 23 Jun 06, Suitability Screening, Medical Assignment Screening and Exceptional Family Member Program (EFMP) Identification and Enrollment

To authorize the release of the patient’s medical information, please enter the name of the Military Treatment Facility or Provider here.

If the EFM/patient is at Age of Majority, he/she must sign the medical summary. EFMP paperwork can be signed by sponsor’s spouse if the patient is a child under the Age of Majority.

DD Form 2792Page 1

Completed by family

Please check the appropriate box here depending upon the purpose- Enrollment, change in status, etc.

If the EFM/patient is at Age of Majority, he/she must sign the medical summary. EFMP paperwork can be signed by sponsor’s spouse if the patient is a child under the Age of Majority.

DD Form 2792Page 2

Completed by family

DD Form 2792Page 3

This page is to be completed by EFMP coordinator

EFMP Coordinator reviews, package for completeness and signs certifying it is complete.

EFMP Coordinator

Please have a qualified medical provider (who knows pt best, PCM, Specialist, or combination) fill out the Medical Summary section beginning here.

NOTE: It is important that the provider also fills out and sign the Asthma, Mental Health and Autism/Developmental Delay Addenda, even if no history of one or more of them exists.

DD Form 2792Page 4

Completed by provider

ICD9 codes are

mandatory!!

DD Form 2792Page 5

What is the prognosis for each active diagnosis?

What is the treatment plan for each diagnosis?

If none or not applicable it should be stated.

Completed by provider

DD Form 2792Page 6 Completed by

provider

Based on the patient’s diagnosis(es), what is the minimum required care that the patient will need?

Please have the medical provider sign and date here.

DD Form 2792Page 7

Completed by provider

Please have the medical provider sign and date here, regardless of whether he/she checked “NO” or “YES” above.

DD Form 2792Page 8

Please be sure the medical provider checks “NO” or “YES” here. If “YES,” the rest of the Asthma/Reactive Airway Disease Summary addendum must be completed.

Completed by provider

DD Form 2792Page 9

Please be sure the medical provider checks “NO” or “YES” here. If “YES,” the rest of the Mental Health Summary addendum must be completed.

ICD9 codes are

mandatory!!

Completed by provider

Please have the medical provider sign and date here, regardless of whether he/she checked “NO” or “YES” on Page 9.

DD Form 2792Page 10

Completed by provider

Please have the medical provider sign and date here, regardless of whether he/she checked “NO” or “YES” above.

DD Form 2792Page 11

Completed by provider

Please be sure the medical provider checks “NO” or “YES” here. If “YES,” the rest of the Autism Spectrum Disorder and Significant Developmental Delay addendum must be completed.

Additional Information can be obtained by contacting your local EFMP Coordinator

Installation EFMP Coordinator Family Support LiaisonNaval Medical Center Portsmouth 757-953-2935 757-953-7805

757-953-8761757-953-8895

JEB Little Creek/Fort Story 757-953-8274 757-462-7563NAS Oceana 757-953-3778 757-433-2912Dam Neck Annex 757-953-9902 Contact Oceana LiaisonNorthwest Annex 757-953-6283 Contact Portsmouth LiaisonYorktown/NNSY 757-953-8415 757-887-4606ARMY 757-314-7923 757-878-1954Air Force 757-225-5950 757-764-3990Marine Corps 757-953-2270Coast Guard 757-686-4025

757-444-2102

Hampton Roads EFMP Point of Contacts

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Contact Information