EFMP Forms

Enrollment, respite care, and other forms needed for EFMP are included.

If you are having difficulty opening the forms, please email us at efmphh@usmc-mccs.org and we will be more than happy to send you the forms via email. Thank you.

Enrollment

• DD 2792 (Medical Summary) - (PDF 110KB)
• DD 2792 (Medical Summary) - Fillable - (PDF 110KB)
• DD 2792-1 (Special Education Summary) - (PDF 70KB)
• DD 2792-1 (Special Education Summary) - Fillable - (PDF 70KB)
• DD Form 2792 (Instructions) - (PDF 172KB)
• DD Form 2792-1 (Instructions) - (PDF 187KB)

General

• Authorization to Release and Consent to Exchange Information (PDF 1.3MB)
• Family Support Service Declination Form (NAVMC11719) – (PDF 31KB)
• Henderson Hall EFMP Customer Rights and Responsibilities (PDF 310KB)
• Henderson Hall EFMP Quarterly Survey/Special Needs Forum
• Henderson Hall EFMP Standards of Service (PDF 226KB)
• Incapacitated Adult: Instructions for designating a disabled child (over 21) as a permanent dependent.
• Notification Of Privacy Limitations (PDF 169KB)
• PCS Needs Assessment (PDF 221KB)

Respite Care Reimbursement Program

• Henderson Hall EFMP Respite Care Packet (PDF 1.5MB)
• Respite Care Log (fillable) – (PDF 3.1MB) – Please use Internet Explorer to open this file
• Hold Harmless Agreement (PDF 175KB)