1. Highlights for the Completion of DD Form 2792
NAVAL MEDICAL CENTER PORTSMOUTH
EFMP COORDINATOR OFFICE
Highlights for the Completion of DD Form 2792
“Family Member Medical Summary”
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).

2. 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

3. Completed by family DD Form 2792 Page 1
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.

4. Completed by family DD Form 2792 Page 2
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.

5. EFMP Coordinator 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.

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

7. What is the prognosis for each active diagnosis?
DD Form 2792
Page 5
Completed by provider
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.

8. DD Form 2792
Page 6
Completed by provider
Based on the patient’s diagnosis(es), what is the minimum required care that the patient will need?

9. Completed by provider DD Form 2792 Page 7
Please have the medical provider sign and date here.

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

11. ICD9 codes are mandatory!!
DD Form 2792
Page 9
Completed by provider
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!!

12. Completed by provider DD Form 2792 Page 10
Please have the medical provider sign and date here, regardless of whether he/she checked “NO” or “YES” on Page 9.

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

14. Contact Information
Additional Information can be obtained by contacting your local EFMP Coordinator