Highlights for the Completion of DD Form 2792 “Family Member Medical Summary” NAVAL MEDICAL CENTER PORTSMOUTH EFMP COORDINATOR OFFICE DD Form 2792 must be completed for all EFMP enrollees. DD Form 2792 (and DD Form , 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 , 20 Dec 05, Authorizing Special Needs Family Members Travel Overseas at Government Expense SECNAV Instruction B, 14 Dec 05, Exceptional Family Member Program OPNAV Instruction 1754.D, 03 NOV 10, Exceptional Family Member (EFM) Program BUMED Instruction A, 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 2792 Page 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 2792 Page 2 Completed by family

DD Form 2792 Page 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 2792 Page 4-6 Completed by provider ICD9 codes are mandatory!!

Please have the medical provider sign and date here. DD Form 2792 Page 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 2792 Page 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 2792 Page 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. Completed by provider ICD9 codes are mandatory!!

Please have the medical provider sign and date here, regardless of whether he/she checked “NO” or “YES” on Page 9. DD Form 2792 Page 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 2792 Page 11 Completed by provider

Questions, comments or suggestions?? Merri Bair