2011 form medical-2026

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The document provides detailed instructions for completing the DD Form 2792, which is a Family Member Medical Summary used to identify family members with special medical needs within the Exceptional Family Member Program (EFMP). It outlines the necessary sections to be filled out, including demographics, medical history, and required addenda for specific conditions such as asthma, mental health issues, and autism spectrum disorders. The form must be completed by a qualified medical professional and includes guidelines for authorization of medical information disclosure under HIPAA regulations.

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Begin by filling out the Demographics/Certification section on page 2. Ensure you provide accurate information about the family member, including their name, date of birth, and any relevant medical history.
In Item 3, list all active diagnoses for the family member. Use one line per diagnosis and include ICD or DSM designations as required.
Complete the Medical Summary section starting on page 4. This part must be filled out by a qualified medical professional, detailing treatment plans and prognosis for each diagnosis.
If applicable, complete any required addenda related to asthma, mental health, or autism spectrum disorders. These addenda should only be filled out if indicated in Item 10 of the main form.
Review all entries for accuracy before signing. The Parent/Guardian or Person of Majority Age must certify that all information is correct in Item 6 on page 2.

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