INSTRUCTIONS FOR COMPLETING DD FORM 2792 FAMILY MEMBER MEDICAL SUMMARY A

Transcription

1 INSTRUCTIONS FOR COMPLETING DD FORM 2792 FAMILY MEMBER MEDICAL SUMMARY A current version of the DD Form 2792 (AUG 2014) must be completed and signed by: A state licensed physician OR A certified/credentialed allied health care provider who is accepted by the Chief, US Navy Bureau of Medicine and Surgery (BUMED) DO NOT have a social worker, therapist, or psychologist sign the DD Form NOTE: Completed forms must be received by HQMC EFMP within 90 days of medical provider s signature.

2 Must have authorization for disclosure for EACH doctor seen MTF = Military Treatment Facility DTF = Dental Treatment Facility Sponsor/Parent to complete page 1 NOTE: Anyone over the age of 18 years old MUST sign their own form (unless DPOA, conservatorship, guardianship, etc.) SIGNATURE Page 1 of 11

3 Basic Demographic Information Sponsor/Parent /Person of Majority Age completes this page Family Member Prefix Spouse: 30 Children: Other Dependents: Page 2 of 11

4 SPONSOR/PARENT/ PERSON OF MAJORITY AGE: After the form is completed by the medical professional, review for completeness & accuracy, then certify (blocks 11 a c). SIGNATURE LEAVE Block 12 BLANK USMC EFMP will certify Page 3 of 11

5 Each block must be THOROUGHLY completed by the provider with as much detail as possible. All information must be LEGIBLE. Page 4 & 5 of 11

6 1.) TYPE of PROVIDER and 2.) the FREQUENCY of provider visits must be completed, using the Frequency of Care legend in Block 22. This page will be returned to the sponsor if not completed. Page 6 of 11

7 Medical provider should add detailed information and justification. Henderson Hall EFMP Ensure that the medical provider indicates all environmental and architectural considerations. This can help determine housing needs. All information must be LEGIBLE. Medical provider to complete blocks 27 a - f. Make sure medical provider includes contact information. Medical Provider Signature Page 7 of 11

8 ASTHMA ADDENDUM HAVE MEDICAL PROVIDER COMPLETE ADDENDA ONLY IF INDICATED ON PAGE 4 (block 1). Medical Provider Signature Page 8 of 11

9 MENTAL HEALTH ADDENDUM HAVE MEDICAL PROVIDER COMPLETE ADDENDA ONLY IF INDICATED ON PAGE 4 (block 1). Page 9 & 10 of 11

10 AUTISM ADDENDUM HAVE MEDICAL PROVIDER COMPLETE ADDENDA ONLY IF INDICATED ON PAGE 4 (block 1). Provider Signature Page 11 of 11

11 Helpful Hints Page 1 can be signed by a sponsor, spouse, or person of majority age. This page gives the medical provider permission to disclose medical information to EFMP. Pages 4-7 are completed and signed by the medical provider. Ensure when the provider completes the form, it is fully completed and legibly written or stamped; frequency is noted properly on page 6; and is signed at the bottom of page 7, and has the required contact information of the medical provider. Pages 8-11 should be completed in conjunction with completed pages 4 & 5 when the provider notes that addenda will be provided. Provide as much detail as possible. Page 3 should be certified AFTER the medical provider has completed the forms and it has been reviewed by the sponsor/parent/person of majority age for completeness, legibility, and accuracy. When the DD Form 2792 is complete, please scan and to or directly to your Family Case Worker. You may also bring a copy to your local USMC EFMP office. Once the DD Form 2792 (AUG 2014) is received by our EFMP office, it will be processed and forwarded to HQMC EFMP for enrollment eligibility determination. The sponsor will receive official notification from HQMC EFMP via military or postal mail to let them know the process is complete.