Important Highlights for the Completion of DD Form 2792 Family Member Medical Summary MCCS Camp Allen EFMP 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 (per MCO B). Please be sure to use the most current version of the form, which has DD Form 2792, APR 2011 on the bottom of the pages. If the EFM is a child, regardless of age, a DD Form must also be completed and submitted with the DD Form (Please see the other set of instructions for the completion of DD Form )

To authorize the release of the patients 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 sponsors spouse if the patient is a child under the Age of Majority. DD Form 2792 Page 1

Please check the appropriate box here depending upon the purpose of the completion of this particular DD Form 2792 (enrollment vs. update, etc.). If the EFM/patient is at Age of Majority, he/she must sign the medical summary. EFMP paperwork can be signed by sponsors spouse if the patient is a child under the Age of Majority. DD Form 2792 Page 2

Please have a qualified medical provider fill out the Medical Summary section beginning here. NOTE: It is important that the provider also fills out 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

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

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.

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.

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

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