Table of Contents – EFMP Wireframes
• Guide to reading wireframe slides
• Enrollment Functions
• Assignment Functions
• Fa...
Guide to reading the WebEFMP Design Wireframes
Use case ID in Caliber
Business Rule ID in Caliber
UI elements will be show...
WebEFMP Dashboard
Req ID Role Name C R U D
FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator role.
X
FR1.7....
US. Army Logo EFMP LogoWelcome, <logged on user>
Last logon: MM/DD/YYYY 00:00
USE CASE(s) UC696707
BUSINESS RULE(s) BR6967...
USE CASE(s) UC702053
BUSINESS RULE(s) NONE
ROLE(s) All EFMP Users
UI Control ID UC702052
PAGE RESOURCES
Appendix A AR-
608...
WebEFMP Enrollment Functions
Req ID Role Name C R U D
FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator rol...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) ALL registered EFMP users
EFMP Enrollment Action:
1. EFMP Registration / Enrollment U...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) ALL registered EFMP users
Review Enrollment Attach Forms Review Forms Create EFM Reco...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) ALL registered EFMP users
UI Control ID
Family Member Demographic Page 3
FM First Nam...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) SNA
UI Control ID
Family Member
Demographic -
Page 3 continued – Case
Manager Informa...
USE CASE(s)
BUSINESS RULE(s)
ROLE(S) SNA
UI Control ID
Continuation of last page Special Assignment
Consideration
Dashboar...
USE CASE(s)
BUSINESS RULE(s) Page ONLY available to EFMP Admin
ROLE(s) SNA
UI Control ID
Administrative Use Required Actio...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) MTF
UI Control ID
Medical Summary Page 4
FM First Name: FIRST_NM X(30)
FM Last Name: ...
EFM_DIAG_CAT_CD-DIAGNOSIS TABLE
USE CASE(s)
BUSINESS RULE(s)
ROLE(s)
UI Control ID
Medical Summary Page 4 (Primary Diagnos...
USE CASE(s)
BUSINESS RULE(s)
ROLE(S)
UI Control ID
Medical Summary Secondary Diagnosis screen
(if applicable
FM First Name...
EFM_DIAG_CAT_CD-DIAGNOSIS TABLE
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) MTF Case Coordinator, EFMP Physician
UI Control ID
Me...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) MTF Case Coordinator
UI Control ID
Medical Summary – Part
B
Page 6 ()
FIRST_NM, MIDDL...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s)
UI Control ID
Certification Signature Page that
completes enrollment
Dashboard Enroll...
Placeholder – Section dedicated to resource pages and checklists. These fall outside the
EFMP flow and are used as support...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) All users
UI Control ID
Dashboard Enrollment Assignment Family Travel Reports Ad Hoc ...
Except where otherwise indicated below, the following forms are available as
follows: DA forms are available on the
APD We...
**1. Soldier already enrolled in EFMP and record flagged. Human
Resource Command queries medical and educational
authoriti...
US. Army Logo EFMP LogoWelcome, <logged on user>
Last logon: MM/DD/YYYY 00:00
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) HRC EFM...
USE CASE(s)
BUSINESS RULE(s)
ROLE(s) All users
UI Control ID
Dashboard Enrollment Assignment Family Travel Reports Ad Hoc ...
1. The Soldier obtains the authenticated DA 5888 and DA 7246
from the losing Military Personnel Division(MPD) at the Levy
...
US. Army Logo EFMP LogoWelcome, <logged on user>
Last logon: MM/DD/YYYY 00:00
USE CASE(s)
BUSINESS RULE(s)
ROLE(s)
EFMP Fa...
Reference Documents
• DD-2792 Links to appropriate UI grouping in WebEFMP
FIRST_NM, MIDDLE_NM, LAST_NM
–EFM TABLE
AUTH_SIG_NM (SIGNATURE TBL) FAM_MBR_PREFIX_CD,
EFM_ADDRESS TABLE
AUTH_SIG_DT,
(SIG...
EFM_REQ_ACTN_CD -EFM ENROLLMENT TBL
EFM_ENRL_CHG_CD -EFM ENROLLMENT TBL
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE FIRST, MID...
FIRST, MIDDLE, LAST NM – SPONSOR TABLEFIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
EFM_REQ_ACTN_CD -EFM ENROLLMENT TBL EFM_ENRL...
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
FIRST, MIDDLE, LAST NM –
SPONSOR TABLE SSN-SPONSOR
TABLE
ADDEND_REQ_CD, EFM ENROLL...
SAME AS PAGE 4
SSN-SPONSOR
TABLE
FIRST, MIDDLE, LAST NM – SPONSOR TABLEFIRST, MIDDLE, LAST NM – EFM TABLE
MEDICAL SUMMARY ...
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
EFM_HLTHPR_CD,
EFM ENROLLMENT
TABLE
ACTY_FREQ_CD,
REQUIRED CARE
TABLE
EFM_HLTHPRR_...
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
ARTFCL_OPE
N_IN_CD,
ARTFCL OPEN
TBLE
ARTFCL_OPENING_CD, ARTFCL OPEN
TBLE CMT_TX, A...
ICD_CD – ADDENDUM 1 TABLE
SAME AS PAGE 7
ADDEND_REQ_CD IN MEDICATION TABLE PROVIDES INFO IN ADDENDUM USING
THE MEDCTN_ID I...
FIRST_NM, MIDDLE_NM,
LAST_NM, SPONSOR TBLFIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
ICD_CD-ADDENDUM 2 TABLE AGE_YR_QY ADDEN 2...
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
CMT_TX, ADDENDUM 2 TBL
TRTMT_PROV_CD, PSYCHIC_FREQ_CD,
PSYCHOL_FREQ_CD,
SOC_WK_FRE...
FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE
FIRST_NM, MIDDLE_NM,
LAST_NM, SPONSOR TABLE
EFM_AUT_DELAY_CD, ADDENDUM 3 TBL
AGE_Y...
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  • 1. Identify a set of key end users who collectively have the credibility to define the software the team is building.
    2. Interview the end users to create a set of preliminary requirements.
    3. Build a simple, interactive user interface prototype.
    4. Show the simple user interface prototype to the key end users and solicit their feedback. Continue revising the simple prototype, keeping it simple, showing it the end users, and revising it again until the end users are excited about the software concept.
    5. Develop a style guide that codifies the prototype’s look and feel, review it, and put it under change control.
    6. Fully extend the prototype until it demonstrates every functional area of the software. Make the prototype broad enough to cover the whole system, but keep it as shallow as possible. It should demonstrate the functional area, not actually implement it.
    7. Treat the fully-extended prototype as the baseline specification. Put it under change control. Then require the developed software to match the prototype exactly, except for changes approved through the change control process.
    8. Write the detailed end-user documentation based on the prototype. This detailed end-user documentation will become the detailed software specification, and it should also be put under change control.
    9. Create a separate, non user interface requirements document for algorithms, interactions with other hardware and software, and so on. Put that document under change control.
  • Identify a Set of Key End Users
    The first step in gathering requirements is to identify a set of users who will provide guidance in defining software requirements. These users must be selected in such a way that if they say that a feature is important, you can believe that it truly is important. Likewise, if they say that a feature can be left out, you should be confident that you truly can leave it out. Be sure to include both power users and average users.

    Build a Simple User Interface Prototype
    Keep the prototype as simple as possible. The point of this activity is to present many different alternatives to the user before you commit much effort to any particular approach. The project team should develop just enough to give the user the look and feel of the software you’re going for, and nothing more. If you want to prototype a report format, for example, don’t even bother to have the UI prototype print the report

    User Paper Storyboards
    One low-tech approach to user interface prototypes is the use of paper storyboards. In this approach, developers or end users start the prototyping process by drawing pictures of the screens, dialogs, toolbars, and other elements they would like the software to have
  • Online tool can be used by individual contributors at different MTFs
    Dashboard allows a "big picture view" of an EFMP enrollment period
  • EFMP updates have ran and the TAPDBs have the EFMP flag selected on the Soldiers record
  • Soldier initiates the Family Member Deployment Screening Form (DA 5888) and personnel validates in DEERS, then signs the DA 5888 prior to the medical screening appointments. (AR 608-75, App E, pt A)
    Soldier and Family contact health clinic for screening appointment. Appointments are scheduled for ALL family members with the EFMP physician to determine if enrollment is warranted for EFMP. (AR 608-75, 1-21d stipulates family members will have same access to care as Active Duty, but does not specify a time frame.) Case coordinator reviews last 5 years of all family member medical records.
    IF YES, Enrollment is warranted, EFMP Physician completes the DD 2792, and coordinates for the DD 2792-1 (AR 608-75, Appendix E). All forms reviewed with Family, signed and stamped by case coordinator
    IF NO, enrollment is not warranted, DA 5888 is completed and Soldier returns the DA 5888 to Unit S-1


  • WireFrames_04292015_Broyles

    1. 1. Table of Contents – EFMP Wireframes • Guide to reading wireframe slides • Enrollment Functions • Assignment Functions • Family Travel • OCONUS • CONUS • Reports • Ad Hoc
    2. 2. Guide to reading the WebEFMP Design Wireframes Use case ID in Caliber Business Rule ID in Caliber UI elements will be shown with a sequence # indicates tab order Page # of screen, multiple screens can be associated with a tab Link to UI drop-list values Data element names and tables linked to UI. DataelementlinktoUI Tabs are associated with EFMP roles and standard processes. Pulled from current logged on user id Italicized text in this box shade indicate comments for the developer. DD2792 – pg. 2 Sec 1-3 Links to the referent sections of the DD2792 / 2792-1. All UI elements (text boxes, drop lists, tables, are documented in Caliber child ID of the tab . Tabs and shortcuts are like headers and footers in the EFMP application. Shortcut links always available UI Control ID in Caliber
    3. 3. WebEFMP Dashboard Req ID Role Name C R U D FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator role. X FR1.7.0.0 MTF Special Needs Advisor (SNA) role. X FR1.8.0.0 Regional Medical Command (RMC) Staff role. X FR1.9.0.0 RMC EFMP Manager role. X FR1.10.0.0 HRC EFMP Special Actions Branch (SAB) role. X FR1.11.0.0 HRC EFMP SAB Manager role. X FR1.12.0.0 EFMP MEDCOM Manager role. X FR1.13.0.0 Army Community Service (ACS) EFMP Manager role. X FR1.14.0.0 ACS Education Reviewer role. X FR1.15.0.0 ACS EFMP System Navigator role. X FR1.16.0.0 HRC Branch Manager (BM) role. X FR1.17.0.0 Administrator role. X ROLE-BASED PERMISSIONS (CRUD) - Dashboard • FR1.4.0.0 The solution shall display user's last successful login. • FR1.5.0.0 The solution shall track actions made by the users. • TR1.5.1.0 The solution shall record user who inputs data. • TR1.5.2.0 The solution shall record date/time. • TR1.5.3.0 The solution shall record user location (MTF/RMC). • TR1.5.4.0 The solution shall record workflow audit logs. • TR1.5.5.0 The solution shall record date/time of entry/exit queues. Requirements Use Case As a USER I want to log on to the application and view a read-only summarized list of current actions / events which are tied to my user_id. Any record, identified by the ENROLLMENT_ID
    4. 4. US. Army Logo EFMP LogoWelcome, <logged on user> Last logon: MM/DD/YYYY 00:00 USE CASE(s) UC696707 BUSINESS RULE(s) BR696709 ROLE(S) ALL registered EFMP users EFMP Dashboard EFM_ENRL_ID DOD_ID_NR TEXT COMMENT SPONSOR CONTACT 1234 9971 DD-2792 marked complete sponsor9971@mail.mil – 555-555-5555 5678 1066 2792-1 uploaded by user_id 1066 sponsor1066@mail.mil – 555-555-5555 Alerts Search by EFM_ENRL_ID Submit UI Control ID DB1 Page(s) 1-Page EFM_ENRL_ID DOD_ID_NR Pulled from current logged on user id Need to verify that enrollment ID is the search value desired. EFMP dashboard is listed in Caliber under Products > User Interface > ID# PRD69670. The Business Requirement is BZ696708. The dashboard is read- only and does NOT write to any table Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    5. 5. USE CASE(s) UC702053 BUSINESS RULE(s) NONE ROLE(s) All EFMP Users UI Control ID UC702052 PAGE RESOURCES Appendix A AR- 608-75 Section 1 “Required Publications” Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources DA Form 5187 Application for Respite Caregivers. (Prescribed in para 2–5.) DA Form 5188 Medical Report on Applicant for Certification to Provide Care for Children or Adults with Disabilities. (Prescribed in para 2–5.) DA Form 5189 Application for Respite Care for Children and Adults with Disabilities. (Prescribed in para 2–5.) DA Form 5190 Clinician’s Information. (Prescribed in para 2–5.) DA Form 5191 Information on Individual with Disability. (Prescribed in para 2–5.) DA Form 5512 Respite Care Agreement. (Prescribed in para 2–5.) DA Form 5863 Exceptional Family Member Program Information Sheet. (Prescribed in para 3–3.) DA Form 5888 Family Member Deployment Screening Sheet. (Prescribed in para 1–29.) DA Form 5888–1 Screening of Family Members in Remote OCONUS Areas. (Prescribed in para 2–1.) DA Form 7246 Exceptional Family Member Program (EFMP) Screening Questionnaire. (Prescribed in para 1–26.) DA Form 7413 Exceptional Family Member Program (EFMP) Assignment Coordination Sheet. (Prescribed in para 1–15.) DA Form 7415 Exceptional Family Member Program (EFMP) Querying Sheet. (Prescribed in para 1–25.) DA Form 7625–1 Army Child and Youth Services Health Screening Tool (Prescribed in para 1–25b.) DA Form 7625–2 Army Child and Youth Services Program Placement Checklist (Prescribed in para 1–25c.) http://armypubs.army.mil/epubs/pdf/r608_75.pdf
    6. 6. WebEFMP Enrollment Functions Req ID Role Name C R U D FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator role. X X X FR1.7.0.0 MTF Special Needs Advisor (SNA) role. X FR1.8.0.0 Regional Medical Command (RMC) Staff role. X FR1.9.0.0 RMC EFMP Manager role. X FR1.10.0.0 HRC EFMP Special Actions Branch (SAB) role. X FR1.11.0.0 HRC EFMP SAB Manager role. X FR1.12.0.0 EFMP MEDCOM Manager role. X FR1.13.0.0 Army Community Service (ACS) EFMP Manager role. X FR1.14.0.0 ACS Education Reviewer role. X FR1.15.0.0 ACS EFMP System Navigator role. X FR1.16.0.0 HRC Branch Manager (BM) role. X X FR1.17.0.0 Administrator role. X X X X ROLE-BASED PERMISSIONS (CRUD) – Enrollment Tab Page 1 • FR1.6.0.0 The solution shall have a Medical Treatment Facility (MTF) EFMP Case Coordinator role. • FR1.7.0.0 The solution shall have a MTF Special Needs Advisor (SNA) role. • FR1.8.0.0 The solution shall have a Regional Medical Command (RMC) Staff role. • FR1.9.0.0 The solution shall have a RMC EFMP Manager role. • FR1.10.0.0 The solution shall have a HRC EFMP Special Actions Branch (SAB) role. • FR1.11.0.0 The solution shall have a HRC EFMP SAB Manager role. • FR1.12.0.0 The solution shall have an EFMP MEDCOM Manager role. • FR1.13.0.0 The solution shall have an Army Community Service (ACS) EFMP Manager role. • FR1.14.0.0 The solution shall have an ACS Education Reviewer role. • FR1.15.0.0 The solution shall have an ACS EFMP System Navigator role. • FR1.16.0.0 The solution shall have a HRC Branch Manager (BM) role. • FR1.17.0.0 The solution shall have an administrator role. Requirements Use Case As a
    7. 7. USE CASE(s) BUSINESS RULE(s) ROLE(s) ALL registered EFMP users EFMP Enrollment Action: 1. EFMP Registration / Enrollment Update 2. Request Change in EFMP Status: a. No longer Have Previously Identified Condition b. No longer Qualifies as a Dependent c. Family Member Deceased d. Divorce / Change in Custody 3. Request for Government Sponsored Travel 1-Enrollment Action Select UI 2-MTF Location Select UI Medical Treatment Facility: 5-Date Entered Date Entered: 6-Certification Date Entered Date of Certification: 3-Data Entry Person Name Text Data Entry Person: 4-Certifying Person Name Text Name of Certifying Person: UI Control ID UI-EN1 Page 1 EFM_REQ_ACTN_CD EFM ENROLLMENT TBL EFM__ENRL_CHG_CD EFM ENROLLMENT TBL DD2792 – pg. 2, Sec 1 Enrollment action list values The developer will have flexibility on GUI real-estate. All screens shown are wireframes only and is open to interpretation. Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query http://www.tricare.mil/
    8. 8. USE CASE(s) BUSINESS RULE(s) ROLE(s) ALL registered EFMP users Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources UI Control ID Sponsor Demographic Page 2 EFM_ADDRESS SPONSOR_ADDRESS SPONSOR Sponsor Information First Name: FIRST_NM X(30) Last Name: LAST_NM X(30) Middle Name: MIDDLE_NM X(30) SSN: SSN 9(09) Installation of Assignment: UIC X(06) Service: SVC_COMP_CD A(01) Status: Regular Active Service Member or Reserves Email: EMAIL_ADDR_TX x(100) Duty Phone: Phone_NR x(20) Mobile Number: Phone_NR x(20) Both Spouses on Active Duty: Boolean, Checkbox DD2792 – pg. 2, Sec 3 - 4 Street Address 1: ADDR_LOC_TX X(120) Street Address 2: ADD_LOC_CONT2_TX X(200) City: LOC_CITY_NM X(50) State: STATE_CD X(02) Postal Code: ADDR_ZIP_CD 9(09) Sponsor Home Address Sponsor Unit Address Street Address 1: ADDR_LOC_TX X(120) Street Address 2: ADD_LOC_CONT2_TX X(200) City: LOC_CITY_NM X(50) State: STATE_CD X(02) Postal Code: ADDR_ZIP_CD 9(09) Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query
    9. 9. USE CASE(s) BUSINESS RULE(s) ROLE(s) ALL registered EFMP users UI Control ID Family Member Demographic Page 3 FM First Name: FIRST_NM X(30) FM Last Name: LAST_NM X(30) FM Middle Name: MIDDLE_NM X(30) Sponsor SSN / ID: SSN 9(09) FM Prefix: ?? Explanation of Residence Family Member Information Gender: Male or Female FM Date of Birth: LAST_NM X(30) FM Home Telephone: MIDDLE_NM X(30) FM Home Email: SSN 9(09) FM Resides with Sponsor Yes or No If “Resides with Sponsor value” = NO then this is enabled DD2792 – pg. 2, Sec 3 - 4 FIRST, MIDDLE, LAST NM – SPONSOR TABLE SSN – SPONSOR TABLE Read only display of Sponsor information above the family member information entry fields Is Sponsor Dual Military or Spouse Former Military: Yes or No ( If Yes, enable row below) Spouse’s Name (Last, First, Middle Initial) FIRST_NM, LAST_NM, MIDDLE_NM – SPOUSE TBL Branch of Service UNIFD_SVC_CD-SPS TBL Rank / Rate RANK_AB-SPOUSE TBL Spouse SSN SPOUSE_SSN Is Family Member Enrolled in DEERS or ever been enrolled in DEERS under a different sponsor’s name or SSN?: Yes or No ( If Yes, enable rows below) Does this Family Member receive case management services: Yes or No ( If Yes, enable rows below) If Yes, under what SSN? SSN-EFM ADDRESS TBL Name of Sponsor (Last, First, Middle Initial) FIRST_NM, LAST_NM, MIDDLE_NM - SPONSOR Branch of Service UNIFD_SVC_CD-SPS TBL Location of Case Manager (x) EFM_DEERS_IN_CD – EFM TABLE EFM_CASE_MGMT_IN_CD – EFM TABLE Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    10. 10. USE CASE(s) BUSINESS RULE(s) ROLE(s) SNA UI Control ID Family Member Demographic - Page 3 continued – Case Manager Information Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query DD2792 – pg. 2, Sec 3 - 4 FIRST, MIDDLE, LAST NM – FAM MEMBR TABLE SSN – SPONSOR TABLE Name (Last, First, Middle Initial) FIRST_NM, LAST_NM, MIDDLE_NM – CASE MANAGER TBL Email Address EMAIL_ADDR_TX – CASE MANAGER TABLE Telephone Number (Include Area Code / Country Code) PHONE_NR, - CASE MANAGER TABLE Case Manager Contact Information a. COCHLEAR IMPLANT If applicable: (1) MAKE MED_EQUIP_MAKE_TX – MEDICAL EQUIPMENT TABLE (2) Model MED_EQUIP_MODEL_TX – MEDICAL EQUIPMENT TABLE b. HEARING AIDS If applicable: (1) MAKE (2) Model c. INSULIN PUMP If applicable: (1) MAKE (2) Model d. PACEMAKER If applicable: (1) MAKE (2) Model Other Equipment (Specify and include make and model as appropriate) MED_EQUIP_TYP_CD – ADAPTIVE EQUIPMENT TABLE Medically Necessary Equipment MED_EQUIP_TYP_TX - MEDICAL EQUIMENT TABLE (X 255) Asthma Addendum 1 is required and attached. Mental Health Summary Addendum 2 is required and attached. Autism Spectrum Disorder / Developmental Delay (AS/DD) Addendum 3 is required and attached Required Agenda (Verify required addendum is attached and has been signed. Do NOT submit a blank addendum for EFMP review.) Note to developer: 1st check box indicates that addendum is required, 2nd box indicates that its been uploaded. Your discretion on the placement of a file upload button Need to fit Section 10 of the DD2792 Titled “Special Assignment Consideration (See Next Page)
    11. 11. USE CASE(s) BUSINESS RULE(s) ROLE(S) SNA UI Control ID Continuation of last page Special Assignment Consideration Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query DD2792 – pg. 3, Sec 10 only a. Possible Special Education / Early Intervention SP_ASG_CONS_CD – SPECIAL CONSIDERATIONS TABLE b. Receiving TRICARE Extended Care Health Option (ECHO) Benefits c. Receiving State Medicaid / Medicare Waiver Services Special Assignment Consideration (X all that apply.) Section 10 of the DD2792 Titled “Special Assignment Consideration) shown for information only. Section should be included with the content found in the prior page of this wireframe UI elements shown above should be included with elements shown on prior page Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    12. 12. USE CASE(s) BUSINESS RULE(s) Page ONLY available to EFMP Admin ROLE(s) SNA UI Control ID Administrative Use Required Actions Read only, values populated from Page 3 DD2792 – pg. 3 Sec 8, 9, 10 Required Actions (x one) First Review of Medical History for the Family Member Qualifies for Change in EFMP Status Request for Government Sponsorship / Family Travel Family Member No Longer Has Previously Identified Condition Update to a previous Evaluation for the Family Member Family Member No Longer Qualifies as a Dependent Other (e.g., Extended Care Health Option Eligibility) Family Member Deceased Divorce / Change in Custody If selected enables the four checkboxes below EFM_ENRL_CHG_CD – EFM ENROLLMENT TBL EFM_REQ_ACTN_CD – EFM ENROLLMENT TBL EFM_ENRL_CHG_TX – EFM ENROLLMENT TBL (MEMO FIELD X1000) FIRST, MIDDLE, LAST NM – SPONSOR TABLE SSN – SPONSOR TABLE Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    13. 13. USE CASE(s) BUSINESS RULE(s) ROLE(s) MTF UI Control ID Medical Summary Page 4 FM First Name: FIRST_NM X(30) FM Last Name: LAST_NM X(30) FM Middle Name: MIDDLE_NM X(30) Family Member Information Gender: Male Sponsor SSN / ID SSN 9(09) FM Prefix ??? Read only, values populated from Page 3 DD2792 – pg. 4 Medical Summary Part A “Patient Status” 1-5 Information Included in Addendum (x all that apply) Asthma (Addendum 1) Mental Health/ADHD (Addendum 2) Autism / Developmental Delay (Addendum 13 Primary Diagnosis ICD Code Medication History Current Medications Dosage Frequency MEDCTN_NM-MEDICATION TABLE MEDCTN_DOSAGE_TX-MEDICATION TABLE MEDCTN_TIME_PD_TX-MEDICATION TABLE EFM_DIAG_CAT_CD-DIAGNOSIS TABLE EFM_DIAG_CAT_CD-MEDICATION TABLE Add Secondary DiagnosisEFMP supports up to 3 Secondary Diagnosis. Add event refreshes diagnosis frame Diagnosis frame Prognosis Excellent Good Fair Poor Guarded Unstable Non-Compliant Continuation to the Treatment Plan for Primary Diagnosis ICD_CD, DIAGNOSIS TABLE Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Delete
    14. 14. EFM_DIAG_CAT_CD-DIAGNOSIS TABLE USE CASE(s) BUSINESS RULE(s) ROLE(s) UI Control ID Medical Summary Page 4 (Primary Diagnosis Treatment Plan) FM First Name: FIRST_NM X(30) FM Last Name: LAST_NM X(30) FM Middle Name: MIDDLE_NM X(30) Family Member Information Gender: Male Sponsor SSN / ID SSN 9(09) FM Prefix ??? Read only, values populated from Page 3 DD2792 – pg. 4 Medical Summary Part A “Patient Status” 6 Treatment Plan for Primary Diagnosis (Medical, mental health, surgical procedures or therapies planned or recommended over the next three years) TRTMNT_DESC_TX – HOSPITAL SUPPORT X(1000) Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    15. 15. USE CASE(s) BUSINESS RULE(s) ROLE(S) UI Control ID Medical Summary Secondary Diagnosis screen (if applicable FM First Name: FIRST_NM X(30) FM Last Name: LAST_NM X(30) FM Middle Name: MIDDLE_NM X(30) Family Member Information Gender: Male Sponsor SSN / ID SSN 9(09) FM Prefix ??? Read only, values populated from Page 3 DD2792 – pg. 4 Medical Summary Part A “Patient Status” 1-5 Secondary Diagnosis ICD Code Medication History Current Medications Dosage Frequency MEDCTN_NM-MEDICATION TABLE MEDCTN_DOSAGE_TX-MEDICATION TABLE MEDCTN_TIME_PD_TX-MEDICATION TABLE EFM_DIAG_CAT_CD-DIAGNOSIS TABLE EFM_DIAG_CAT_CD-MEDICATION TABLE Add Secondary DiagnosisEFMP supports up to 3 Secondary Diagnosis. Add event refreshes diagnosis frame Prognosis Excellent Good Fair Poor Guarded Unstable Non-Compliant Continuation to the Treatment Plan for secondary Diagnosis Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    16. 16. EFM_DIAG_CAT_CD-DIAGNOSIS TABLE USE CASE(s) BUSINESS RULE(s) ROLE(s) MTF Case Coordinator, EFMP Physician UI Control ID Medical Summary Page 4 (Secondary Diagnosis Treatment Plan) FM First Name: FIRST_NM X(30) FM Last Name: LAST_NM X(30) FM Middle Name: MIDDLE_NM X(30) Family Member Information Gender: Male Sponsor SSN / ID SSN 9(09) FM Prefix ??? Read only, values populated from Page 3 DD2792 – pg. 4 Medical Summary Part A “Patient Status” 6 Treatment Plan for Secondary Diagnosis (Medical, mental health, surgical procedures or therapies planned or recommended over the next three years) TRTMNT_DESC_TX – HOSPITAL SUPPORT X(1000) Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    17. 17. USE CASE(s) BUSINESS RULE(s) ROLE(s) MTF Case Coordinator UI Control ID Medical Summary – Part B Page 6 () FIRST_NM, MIDDLE_NM, LAST_NM, - EFM TABLE Family Member / Patient Name (Last, First, Middle) FIRST_NM, MIDDLE_NM, LAST_NM, - SPONSOR TABLE DD2792 – pg. 6 Medical Summary Part B “Patient Status” 6 Minimum Health Care Required Sponsor Name (Last, First, Middle) Sponsor SSN (Last 4 digits) SSN-SPONSOR A - Annually B - Bi-Annually Q- Quarterly M - Monthly BI - Bi - Monthly W - Weekly CARE PROVIDER (X as appropriate) Frequency (See above) CARE PROVIDER (X as appropriate) Frequency (See above) C1 A. ALLERGIST IMMUNOLOGIST A - W C9 HH. ORAL SURGEON A - W C2 B. AUDIOLOGIST A - W C10 II. ORTHOPEDIC SURGEON - ADULT A - W C3 A - W C11 A - W C4 A - W C12 A - W C4 A - W C13 A - W C5 A - W C14 A - W C6 A - W C15 A - W C7 A - W C16 A - W C8 A - W C17 A - W Indicate Frequency of Care: X EFM_HLTHPR_CD, EFM ENROLLMENT TABLE ACTY_FREQ_CD, REQUIRED CARE TABLE Notional code values / code test shown. The table illustrated here will require 61 rows (see Page 6 of DD Form 2792) Code values will read from EFM_HLTHPRR_TX from the EFM NRL Table EFM_HLTHPRR_TX, EFM ENRL TBL Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    18. 18. USE CASE(s) BUSINESS RULE(s) ROLE(s) UI Control ID Certification Signature Page that completes enrollment Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query DD2792 – pg. 3, Sec 11 and 12 CERTIFICATION CERTIFICATION. DO NOT CERTIFY BEFORE THE MEDICAL PROVIDER COMPLETES THE ENTIRE FORM AND ADDENDA By signing below, we certify that the information submitted is complete and accurate. Parent / Guardian or Person of Majority Age: EFM_SIGN_CAT_CD, - SIGNATURE TABLE a. Printed Name AUTH_SIG_NM – SIGNATURE TBL b. Signature IND_SIGN_BLOB – SIGNATURE TBL c. Date (YYYYMMDD) AUTH_SIG_DT – SIGNATURE TBL Administrative Certification EFM_SIGN_CAT_CD – SIGNATURE TBL a. Printed Name AUTH_SIG_NM – SIGNATURE TBL b. Signature IND_SIGN_BLOB – SIGNATURE TBL c. Date (YYYYMMDD) AUTH_SIG_DT – SIGNATURE TBL d. Location of Military Treatment Facility or Certifying EFMP Office MTF_CD – EFM ENROLLMENT TBL e. Telephone Number MTF_PHONE_NR, - EFM ENROLLMENT TBL Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources
    19. 19. Placeholder – Section dedicated to resource pages and checklists. These fall outside the EFMP flow and are used as supporting pages navigable from the persistent bottom links
    20. 20. USE CASE(s) BUSINESS RULE(s) ROLE(s) All users UI Control ID Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query DD2792 – pg. 3, Sec 11 and 12 REVIEW ENROLLMENT CHECKLIST Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources Check list items Links to blank forms Who fills out? DA Form 5888 – Family Member Deployment Screening Sheet Attached? http://www.apd.army.mil/pub/eforms/pdf/a5888 .pdf Soldier (Sponsor) * DA Form 5888-1 –Screening of Family Member in Remote OCONUS Areas Attached? (* if applicable http://www.apd.army.mil/pub/eforms/pdf/a5888 _1.pdf Medical Provider DA Form 7246 EFMP Screening Questionnaire Attached? http://www.apd.army.mil/pub/eforms/pdf/a7246 .pdf Soldier (Sponsor) DD 2972 Complete? This application is DD 2972, so check mark is marked when enrollment certification is signed (Sections indicated per wireframes) DD 2792-1 Complete? (if applicable) MTF Special Needs Advisor DD 2792 ADDENDUM 1 Complete? (if applicable) “Asthma / Reactive Airway Disease Summary” MTF Special Needs Advisor (SNA) role DD 2792 ADDENDUM 2 Complete? (if applicable) “Mental Health Summary” MTF Special Needs Advisor (SNA) role A qualified Medical Professional is who needs to review this, AKA EFMP physician but for the application role it is “MTF Special Needs Advisor (SNA) role”
    21. 21. Except where otherwise indicated below, the following forms are available as follows: DA forms are available on the APD Web site (www.apd.army.mil); DD Forms are available at http://www.dior.whs.mil. DA Form 5187 Application for Respite Caregivers. (Prescribed in para 2–5.) DA Form 5188 Medical Report on Applicant for Certification to Provide Care for Children or Adults with Disabilities. (Prescribed in para 2–5.) DA Form 5189 Application for Respite Care for Children and Adults with Disabilities. (Prescribed in para 2–5.) DA Form 5190 Clinician’s Information. (Prescribed in para 2–5.) DA Form 5191 Information on Individual with Disability. (Prescribed in para 2–5.) DA Form 5512 Respite Care Agreement. (Prescribed in para 2–5.) DA Form 5863 Exceptional Family Member Program Information Sheet. (Prescribed in para 3–3.) Support Forms
    22. 22. **1. Soldier already enrolled in EFMP and record flagged. Human Resource Command queries medical and educational authorities at proposed assignment location of availability of respective services based on current enrollment data. (AR 608- 75, 3-2.b.). 2. CONUS Medical Authority has 3 working days from receipt of query to notify HRC of availability of medical resources. (AR 608-75, 3-2, b (3)). 3. OCONUS Medical Authority has 15 calendar days from receipt of query to notify HRC of availability of medical resources. (AR 608-75, 3-2, b (3)). **4. HRC forwards results to the assignment manager. (AR 608-75, 3-2.b (5)). HRC Nominative Phase Req ID Role Name C R U D FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator role. X FR1.7.0.0 MTF Special Needs Advisor (SNA) role. x FR1.8.0.0 Regional Medical Command (RMC) Staff role. x FR1.9.0.0 RMC EFMP Manager role. FR1.10.0.0 HRC EFMP Special Actions Branch (SAB) role. FR1.11.0.0 HRC EFMP SAB Manager role. FR1.12.0.0 EFMP MEDCOM Manager role. FR1.13.0.0 Army Community Service (ACS) EFMP Manager role. FR1.14.0.0 ACS Education Reviewer role. FR1.15.0.0 ACS EFMP System Navigator role. FR1.16.0.0 HRC Branch Manager (BM) role. X FR1.17.0.0 Administrator role. x ROLE-BASED PERMISSIONS (CRUD) – Assignment Tab WebEFMP Assignment Tab Use Case As a USER I want to log on to the application and view a read-only summarized list of current actions / events which are tied to my user_id. Any record, identified by the ENROLLMENT_ID
    23. 23. US. Army Logo EFMP LogoWelcome, <logged on user> Last logon: MM/DD/YYYY 00:00 USE CASE(s) BUSINESS RULE(s) ROLE(s) HRC EFMP Personnel EFMP Assignment UI Control ID Assignment Page 3 Read only, values populated from Sponsor info from Page 3 EnrollmentFIRST, MIDDLE, LAST NM – SPONSOR TABLE SSN – SPONSOR TABLE AR 608-75, 3-2.b Exceptional Family Member Program Soldier already enrolled in EFMP and record flagged. Human Resource Command queries medical and educational authorities at proposed assignment location of availability of respective services based on current enrollment data. EFM_ENRL_ID DOD_ID_NR Phase Notification of Receipt CONUS Medical Authority has 3 working days from receipt of query to notify HRC of availability of medical resources. TEXT COMMENT 1234 9971 Nominative 04/15/2015 DD2792, DD2792-1 signed and marked complete This is the same data that pops up on the dashboard. The user of this page is HRC EFMP folks, they need to see what EFM records have been signed off and now notify MTF personnel Notify Medical UI that sends a notification to a registered user with an MTF role informing that an EFMP enrollee requires medical and/or education services at proposed assignment location. Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query
    24. 24. USE CASE(s) BUSINESS RULE(s) ROLE(s) All users UI Control ID Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query DD2792 – pg. 3, Sec 11 and 12 REVIEW ASSIGNMENT CHECKLIST Review Enrollment Attach Forms Review Forms Create EFM Record Notify Sponsor Resources Check list items Links to blank forms Who fills out? Enrollment certified. Soldiers personnel record is EFMP flagged Soldier (Sponsor) CONUS or OCONUS Assignment Medical Authority Notification time window met based on CONUS or OCONUS requirements Medical Provider Assignment Manager confirms receipt of Medical Authority notification Soldier (Sponsor) Soldier placed on assignment (Sections indicated per wireframes) A qualified Medical Professional is who needs to review this, AKA EFMP physician but for the application role it is “MTF Special Needs Advisor (SNA) role” This is AKA “Nominative Phase” we need to determine how we label this but the flow is established. Once this is fully checked we move to the Family Travel OCONUS if applicable so Family Travel CONUS will NOT be enable if CONUS is selected
    25. 25. 1. The Soldier obtains the authenticated DA 5888 and DA 7246 from the losing Military Personnel Division(MPD) at the Levy Briefing. 2.The Soldier or spouse schedules an OCONUS screening appointment with the EFMP Case Coordinator at the nearest Army Medical Treatment Facility (MTF). NOTE: If necessary, Case Coordinator will assist the family in scheduling a screening at another DoD MTF. 3.The EFMP Case Coordinator conducts the screening appointment at that MTF. 4.A member of the EFMP staff reviews medical records of all family members, and if necessary, arranges fora physical and developmental screening for children 72 months of age and younger, and completes the medical portion of DA 5888. WebEFMP Family Travel Tab Req ID Role Name C R U D FR1.6.0.0 Medical Treatment Facility (MTF) EFMP Case Coordinator role. X FR1.7.0.0 MTF Special Needs Advisor (SNA) role. x FR1.8.0.0 Regional Medical Command (RMC) Staff role. x FR1.9.0.0 RMC EFMP Manager role. FR1.10.0.0 HRC EFMP Special Actions Branch (SAB) role. FR1.11.0.0 HRC EFMP SAB Manager role. FR1.12.0.0 EFMP MEDCOM Manager role. FR1.13.0.0 Army Community Service (ACS) EFMP Manager role. FR1.14.0.0 ACS Education Reviewer role. FR1.15.0.0 ACS EFMP System Navigator role. FR1.16.0.0 HRC Branch Manager (BM) role. X FR1.17.0.0 Administrator role. x ROLE-BASED PERMISSIONS (CRUD) – Assignment Tab Use Case As a USER I want to log on to the application and view a read-only summarized list of current actions / events which are tied to my user_id. Any record, identified by the ENROLLMENT_ID
    26. 26. US. Army Logo EFMP LogoWelcome, <logged on user> Last logon: MM/DD/YYYY 00:00 USE CASE(s) BUSINESS RULE(s) ROLE(s) EFMP Family Travel OCONUS / CONUS UI Control ID Family Travel OCONUS Dashboard Enrollment Assignment Family Travel Reports Ad Hoc Query Check list items – OCONUS Process Y/N Links to blank forms Who fills out? Family Member Deployment Screening Form (DA 5888) is signed? DA 5888 (See AR 608-75, App E, pt A) Soldier (Sponsor) Verify Soldier and Family screening appointment with MTF complete DD 2792 and if applicable DD 2792-1 reviewed, signed and certified? Medical Provider Soldier (Sponsor) (Sections indicated per wireframes) If 2nd item is YES then remainder of list is enabled (by default disabled greyed out) IF 2nd item is NO, then enrollment is rejected
    27. 27. Reference Documents • DD-2792 Links to appropriate UI grouping in WebEFMP
    28. 28. FIRST_NM, MIDDLE_NM, LAST_NM –EFM TABLE AUTH_SIG_NM (SIGNATURE TBL) FAM_MBR_PREFIX_CD, EFM_ADDRESS TABLE AUTH_SIG_DT, (SIGNATURE TBL) Family Member Medical Summary UI: DD2792 Page 1 of 11 NAME OF PATIENT FIRST_NM, MIDDLE_NM, LAST_NM –EFM TABLE SIGNATURE OF PATIENT/PARENT GUARDIAN AUTH_SIG_NM (SIGNATURE TBL) RELATIONSHIP TO PATIENT FAM_MBR_PREFIX_CD, EFM_ADDRESS TABLE DATE AUTH_SIG_DT, (SIGNATURE TBL)
    29. 29. EFM_REQ_ACTN_CD -EFM ENROLLMENT TBL EFM_ENRL_CHG_CD -EFM ENROLLMENT TBL FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE FIRST, MIDDLE, LAST NM – SPONSOR TABLE SSN – SPONSOR TABLE BIRTH_DT-EFM TBL FAM_MBR_PRFIX_CD, EFM TBL DOD_ID_NR-EFM ENROLLMENT ADDR_LOC_TX, ADD_LOC_CONT2,TX, LOC_CITY_NM, STATE_CD, ADDR_ZIP_CD, ADDR_CNTRY_CD, POSTAL_GTWY_OO_AB-EFM_ADDRESS TABLE PHONE_DSG_PURP_CD “H”, - SPONSOR PHONE TBL EMAIL_ADDR_TX – EFM TABLE RANK_AB – SPONSOR TBL ARMY_CLASS_CD, ENL_MOS_CD, WO_MOS_CD, CO_AOC_CO- SPONSOR TABLE ACAP_SITE_CD – SPONSOR TBL UNIFD_SVC_CD – SPS TBL SVC_COMP_CD SPONSOR TBL EMAIL_ADDR_TX – SPONSOR TABLE PHONE_DSG_PURP_CD, PHONE_NR (SPONSOR TABLE) FAM_MBR_RSDNCE_CD (EFM TABLE) DUAL_MIL_CD-EFM ENROLL SSN-EFM ADDRESS TBL FIRST, MIDDLE, LAST NM – SPONSOR TABLE FIRST_NM, LAST_NM, MIDDLE NM – SPOUSE TBL RANK_AB – SPOUSE TBL SPOUSE_SSN – SPOUSE TBL EFM_DEERS_IN_CD- EFM TBL UNIFD_SVC_CD SPONSOR TBLE EFM_CASE_MGT_IN_C D-EFM TBL CASE_MGR_LOC_CD EMAIL_ADDR_TX, CASE MANAGER TABLE PHONE_NR, CASE MGR L31, L04, L22, L23 FROM MED_EQUIP_TYP_CD - ADAPTIVE EQUIPMENT TBL MED_EQUIP_MAKE_TX – MEDICAL EQUIPMENT TBL MED_EQUIP_TYP _TX – MEDICAL EQUIPMENT TBL MED_EQUIP_MODEL_TX – MEDICAL EQUIPMENT TBL UNIFD+SVC_CD, SPONSOR TBL FIRST, MIDDLE, LAST_NM – CASE MANAGER TBL DEMOGRAPHICS / CERTIFICATION UI: DD2792 Page 2 of 11
    30. 30. FIRST, MIDDLE, LAST NM – SPONSOR TABLEFIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE EFM_REQ_ACTN_CD -EFM ENROLLMENT TBL EFM_ENRL_CHG_CD -EFM ENROLLMENT TBL EFM_ENRL_CHG_TX ADDEND_REQ_CD, EFM ENROLLMENT TBLE ATTACH_STAT_CD, ADDENDUM 1, 2 & 3 TBLS SP_ASG_CONS_CD –SPECIAL CONSIDERATIONS TBL EFM_SIGN_CAT_CD, SIGNATURE TABLE EFM_SIGN_CAT_CD, SIGNATURE TABLE AUTH_SIG_NM (SIGNATURE TBL) IND_SIGN_BLOB AUTH_SIG_DT, (SIGNATURE TBL) AUTH_SIG_NM (SIGNATURE TBL) IND_SIGN_BLOB AUTH_SIG_DT, (SIGNATURE TBL) MTF_CD – EFM ENROLLMENT MTF_PHONE_NR, EFM ENROLLMENT TABLE SSN-SPONSOR TABLE REQUIRED ACTIONS / CERTIFICATION UI: DD2792 Page 3 of 11
    31. 31. FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE FIRST, MIDDLE, LAST NM – SPONSOR TABLE SSN-SPONSOR TABLE ADDEND_REQ_CD, EFM ENROLLMENT TBLE ICD_CD-DIAGNOSIS TABLE MEDCTN_NM – MEDICATION TABLE MEDCTN_TIME_PD_TX – MEDICATION TABLE MEDCTN_DOSAGE_TX – MEDICATION TABLE ER_VISIT_QY – HOSPITAL SUPPORT OUT_PTNT_VISIT_QY – HOSPITAL SUPPORT IMPNT_TRTMT_FREQ_QY – HOSPITAL SUPPORT HOSPITALZTN_QY – HOSPITAL SUPPORT EFM_PROGN_CD, HOSPITAL SUPPORT TABLE TRTMNT_DESC_TX – HOSPITAL SUPPORT ICD_CD-DIAGNOSIS TABLE EFM_DIAT_CAT_CD-DIAGNOSIS TABLE EFM_DIAT_CAT_CD-DIAGNOSIS TABLE DIAG_DESIG_CD TO SELECT TYPE OF DIAGNOSIS, THEN MEDCTN_NM, DOSAGE AND TIME PERIOD – MEDICATION TABLE TRTMNT_DESC_TX HOSPITAL SUPPORT TABLE MEDICAL SUMMARY – PART A UI: DD2792 Page 4 of 11
    32. 32. SAME AS PAGE 4 SSN-SPONSOR TABLE FIRST, MIDDLE, LAST NM – SPONSOR TABLEFIRST, MIDDLE, LAST NM – EFM TABLE MEDICAL SUMMARY – PART A CONTINUED UI: DD2792 Page 5 of 11
    33. 33. FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE EFM_HLTHPR_CD, EFM ENROLLMENT TABLE ACTY_FREQ_CD, REQUIRED CARE TABLE EFM_HLTHPRR_TX EFM ENRL TBL SSN-SPONSOR TABLE FIRST, MIDDLE, LAST NM – SPONSOR TABLE MEDICAL SUMMARY – PART B REQUIRED MEDICAL SPECIALTIES UI: DD2792 Page 6 of 11
    34. 34. FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE ARTFCL_OPE N_IN_CD, ARTFCL OPEN TBLE ARTFCL_OPENING_CD, ARTFCL OPEN TBLE CMT_TX, ARTFCL OPEN TBLE ENV_CONS_CD, MEDICAL EQUIP TBLE ENV_CONS_TX, MEDICAL EQUIP TBLE MED_EQUIP_TYP_C D, MEDICAL EQUIP TBLE MED_EQUIP_TYP_T X,, MEDICAL EQUIP TBLE FULL_NM – PROVIDER TABLE AUTH_SIG_DT – PROVIDER TABLE EFM_HLTHPR_CD EFM ENROLLMENT BL PHONE_SYS_CD, PROVDER PHONE TBLE PROVIDER TBL – EMAIL ADDR_TX SSN-SPONSOR TABLE FIRST, MIDDLE, LAST NM – SPONSOR TABLE MEDICAL SUMMARY – PART B CONTINUED UI: DD2792 Page 7 of 11
    35. 35. ICD_CD – ADDENDUM 1 TABLE SAME AS PAGE 7 ADDEND_REQ_CD IN MEDICATION TABLE PROVIDES INFO IN ADDENDUM USING THE MEDCTN_ID IN ADDENDUM1 TABLE ASTHMA_HIST_CD, ADDENDUM 1 TBL ORAL_STER_IN_CD, ADDENDUM1 TABLE ER_VISIT_QY, ADDENDUM1 TABLE LAST_ADM_DT, ADDENDUM1 TABLE ORAL_STER_IN_CD, ADDENDUM1 TABLE ORAL_STER_IN_CD, ADDENDUM1 TABLE HSPLZN_DT, ADDENDUM1 TABLE HOSP_5yr_QY ADDENDUM 1 TBL ICD_SEV_CD, ADDENDUM 1 TBL FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE SSN-SPONSOR TABLE ADDENDUM 1 – ASTHMA/REACTIVE DISEASE SUMMARY UI: DD2792 Page 8 of 11
    36. 36. FIRST_NM, MIDDLE_NM, LAST_NM, SPONSOR TBLFIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE ICD_CD-ADDENDUM 2 TABLE AGE_YR_QY ADDEN 2 ADDEND_REQ_CD IN MEDICATION TABLE PROVIDES INFO IN ADDENDUM USING THE MEDCTN_ID IN ADDENDUM2 TABLE, MEDCTN_DISC_IN_CD– MEDICATION TBL INTVN_THRPY_TX, ADDENDUM 2 TBL ACTU_FREQ_TX, ADDENDUM 2 TBL OUT_PTNT_VISIT_QY, ADDENDUM 2 TBLOUT_PTNT_VISIT_QY, ADDENDUM 2 TBL TRTMNT_QY, ADDENDUM 2 TBL LAST_ADM_DT-ADDENDUM 2 TBL HOSP5YR_QY ADDEND 2 TBL MENTL_HLTH_HIST_CD, ADDENDUM 2 TBL SSN-SPONSOR TABLE ADDENDUM 2 – MENTAL HEALTH SUMMARY UI: DD2792 Page 9 of 11
    37. 37. FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE CMT_TX, ADDENDUM 2 TBL TRTMT_PROV_CD, PSYCHIC_FREQ_CD, PSYCHOL_FREQ_CD, SOC_WK_FREQ_CD, OTHER_FREQ_CD (ALL SAME AS ACTY_FREQ_CD VALUES) TRTMT_PLAN_CMT_TX, ADDENDUM 2 TBL SAME AS PAGE 7 SSN-SPONSOR TABLE ADDENDUM 2 – MENTAL HEALTH SUMMARY CONTINUED UI: DD2792 Page 10 of 11
    38. 38. FIRST_NM, MIDDLE_NM, LAST_NM,-EFM TABLE FIRST_NM, MIDDLE_NM, LAST_NM, SPONSOR TABLE EFM_AUT_DELAY_CD, ADDENDUM 3 TBL AGE_YR_QY, ADDEN 3TBL BIRTH DT, EFM TBL AUTISM_DIAG_SVC_CD, AUTISM DIAG_CD TABLE AND ADDENDUM 3 TABLE? EFM_AUT_DELAY_TX, ADDENDUM 3 TBL AUTISM_DIAG_SVC_TX, ADDENDUM 3 TBL CO_EXST_DIAG_CD COEXISTDIAG TABLE CO_EXST_DIAG_TX, COEXISTDIAG TBL ADDEND_REQ_CD IN MEDICATION TABLE PROVIDES INFO IN ADDENDUM USING THE MEDCTN_ID IN ADDENDUM3TABLE, EFM_IEP_SVC_CD, CURRENT INTERVENTION TBL SCH_HRS_PER_WK_QY, TC_HRS_PER_WK_QY, OTH_HRS_PER_WK_QY, CURRENT INTERVENTION TBL EFM_IEP_SVC_TX, CURRENT INTERVENTION TBL COMM_TYP_CD, ADDENDUM 3TBL EFM_COMM_TYP_CD, ADDENDUM 3TBL INTVTN_THRPY_TX, ADDENDUM 3TBL EFM_BEH_IN_CD, ADDENDUM 3TBL EFM_ED_CD, ADDENDUM 3TBL EFM_COGN_ABIL_CD, ADDENDUM 3TBL USING_RQRD_CARE_ID IN ADDENDUM 3TBL, RQRDCARE TBL HAS REQ_MED_SVC_CD CMT_TX ADDENDUM 3TBL USING_RQRD_CARE_ID IN ADDENDUM 3TBL, RQRDCARE TBL HAS ACTY_FREQ_CD RESP_CARE_SRC_TX, HRS_PER_MO_QY IN ADDENDUM 3TBL SAME AS PAGE 7 SSN-SPONSOR TABLE ADDENDUM 3 – AUTISM SPECTRUM UI: DD2792 Page 11 of 11

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