dd form 2792 pdf
DD FORM 2792, JAN 2021 FAMILY MEMBER MEDICAL
The DD Form 2792 is completed to identify a family member with special medical needs. There is a Certification Section on page 3 that should be signed AFTER
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new york state medicaid program dental policy and
Claim Form A can be obtained from CSC by calling (800) 343-9000. 2. DENTAL SITE IDENTIFICATION: Certain procedure codes require specification of surface
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Exceptional Family Member Program
These enrollment forms are: DD Form 2792, Exceptional Family Member Medical Summary, for medical issues only; DD Form 2792-1, Exceptional Family Member Special
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