Special Care Organizational Record

for Adults with Special Health Care Needs SCOR

■ Table of Contents

Introduction� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

In Case of an Emergency� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4

Birth� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

Routines and Preferences� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

School � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 25

Employment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28

Medical Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 30

Service Providers� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 40

Support � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 45

Health Benefits and Insurance� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49

Transitioning/Moving� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53

Planning Ahead� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 56

Other Resources� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 68

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■■

Introduction 1 

Introduction

The■Special■Care■Organizational■Record■(SCOR)■for■Adults■is■specifically■designed■as■an■organizing■

tool■for■families■with■an■adult■member■with■special■health■care■needs.■This■includes■spouses■and■adult■

children■with■special■health■care■needs■as■well■as■any■other■adult■dependent■family■member.■The■SCOR■

for■Adults■is■intended■to■help■track■and■organize■information■in■one■central■location■and■to■make■it■easier■

for■someone■to■care■for■your■family■member■when■you■are■unable■to■do■so.■While■the■SCOR■is■organized■

into■different■sections,■you■are■encouraged■to■reorganize■it■to■accommodate■your■needs.

Please■note■that■while■the■SCOR■for■Adults■is■a■toolkit■to■help■you■care■for■your■family■member,■it■is■not■

legally■binding■in■any■way■nor■can■it■take■the■place■of■official■medical■records.■It■also■contains■very■private■

information■such■as■Social■Security■numbers,■medical■history/information,■and■insurance■information.■

In■order■to■ensure■that■you■maintain■your■family’s■privacy,■make■sure■to■keep■your■SCOR■in■a■safe■place■

that■is■not■easily■accessible■by■those■who■should■not■have■access■to■it.■

The■SCOR■is■available■in■Adobe■Acrobat■format,■allowing■you■to■type■information■directly■into■the■

forms.■If■you■do■not■have■your■information■readily■available,■save■the■SCOR■and■update■it■later■or■

print■the■forms■you■need■and■fill■them■out■by■hand.■A■printed■copy■of■the■SCOR■is■available■from■your■

installation■Exceptional■Family■Member■Program■(EFMP)■Service■Provider.

If■you■have■any■questions■or■comments■about■the■SCOR■for■Adults,■please■feel■free■to■submit■

them■through■the■MilitaryHOMEFRONT■Feedback link■located■on■the■upper■right■corner■of■the■

MilitaryHOMEFRONT■website■home■page■at■www.militaryhomefront.dod.mil.
Introduction | 2 

SCORs for Adults with Special Health Care Needs Guide

What is the SCOR for Adults?

The■SCOR■for■Adults■is■an■organizing■tool■for■families■who■have■an■adult■family■member■with■special■

health■care■needs.■This■includes■spouses■and■adult■children■with■special■health■care■needs,■as■well■

as■other■adult■dependent■family■members.■It■is■designed■to■help■you■keep■track■of■all■of■the■relevant■

information■regarding■your■family■member’s■health■and■care.■

How can the SCOR help you?

While■caring■for■your■family■member■with■special■health■needs,■you■receive■information■and■paperwork■

that■must■be■readily■accessible.■The■SCOR■will■help■you■organize■all■of■this■information■and■make■it■

easier■for■you■to■quickly■find■what■you■need.■It■will■also■make■it■easier■for■you■to■share■key■information■

with■those■who■are■part■of■your■family■member’s■care■team.

Use the SCOR to

■ track■changes■in■your■family■member’s■medicines■or■treatments;

■ list■telephone■numbers■for■health■care■providers■and■community■organizations;

■ prepare■for■appointments;

■ file■information■about■your■family■member’s■health■history;

■ share■new■information■with■your■family■member’s■primary■doctor■and■others■providing■care;■and

■ review■the■checklist■prior■to■making■a■permanent■change■of■station■(PCS)■move.

Some helpful hints for using your family member’s SCOR:

■ Keep■the■SCOR■where■it■is■easy■to■find■so■it■will■always■be■on■hand■when■you■need■it.

■ Be■mindful■that■the■SCOR■contains■private■information■and■that■it■should■be■kept■in■a■■safe■place.

■ Keep■the■SCOR■as■up-to-date■as■possible.■Add■new■information■to■the■SCOR■whenever■there■is■■

a■change■in■your■family■member’s■treatment.■

■ Bring■the■SCOR■with■you■to■appointments■and■hospital■visits■so■that■information■you■need■will■■

be■close■at■hand.
Introduction | 3 

SCORs for Adults with Special Health Care Needs Guide (continued)

How do you set up your family member’s SCOR? Follow these steps:

STEP 1: Gather information you already have. 

Gather any health information that you already have about your family member. This may include reports

from recent doctor’s visits, immunization records, a summary of a recent hospital stay, test results or

informational pamphlets, etc.

STEP 2: Look through the pages of the SCOR.

Select the pages that you think will be most beneficial to you and tracking your family member’s health

and care. Once you have determined what you need, print out those selected pages.

STEP 3: Decide which information is most important to keep in the SCOR.

What information do you find yourself looking for often? What information do the care providers need

when caring for your family member? Additional, less critical information can be stored in a file drawer or

box where you can find it if needed.

STEP 4: Put the SCOR together.

Organize the SCOR in a way that makes the most sense to you and your family member. Here are some

supplies that may help you put it together:

■ 3-ring binder or large accordion envelope to hold papers securely

■ Tabbed dividers for creating separate sections

■ Pocket dividers for storing reports

■ Plastic pages for storing business cards and photographs

Things to remember about the SCOR:

■ While the SCOR does contain a lot of your family member’s medical history/information, it is

not intended to replace official medical records.

■ It is not legally binding in any way. The SCOR provides a place to start thinking about who would take

care of your family member if you were no longer able to do so. However, you would still need to go

through the proper legal protocol to make these decisions legally binding.

■ It contains very private information (e.g., Social Security numbers, insurance information, medical

history). It is imperative that you keep it in a safe place.
In Case of an Emergency 4 |

■■In Case of an Emergency

Emergency Quick Glance

Name:

Date of Birth: Blood Type:

Address:

Phone:

Diagnosis(es): (For more on diagnoses, 

Medical Information Section.)

go to the “Current Medical Diagnoses” sheet in the 

Emergency contacts: (List■in■order■of■who■should■be■contacted■first■to■last.)

Name Relationship Cell Phone Work Phone Evening Phone
In Case of an Emergency | 5 

Current medications: (For more on medications, go to the “Medication History Tracking” sheet in

the Medical Information Section.)

Start

Date

Stop 

Date

Medication 

(brand/generic)

Prescribed

 by

Dose/ 

Route

Time 

Given

Reason for 

Medication

Medication allergies: (For more on allergies, go to the “Food and Other Allergies” sheet in the

Routines and Preferences Section.)

Allergen Allergic Reaction How To Respond
In Case of an Emergency | 6 

In Case of an Emergency: Emergency Plan

Use the tables below to list any health-related or other emergencies that may occur and how the

emergency should be handled (e.g., if your family member is epileptic and has a seizure or your family

member becomes combative under certain circumstances).

What Might Happen:

What To Do:

Step 1:

Step 2:

Step 3:

Step 4:

Other:

What Might Happen:

What To Do:

Step 1:

Step 2:

Step 3:

Step 4:

Other:
|

■■

Birth 7 

Birth

Personal Information

Name: Prefers to be Called:

Date of Birth: SSN: Blood Type:

Caregivers:

Location of Birth Certificate: 

Location of Social Security Card:

Address:

Phone: Fax: County:

Emergency Contact Name: 

Emergency Contact Number: 

Mother’s

Name: SSN: Sponsor

(Yes/No):

Address: 

Daytime

Phone: 

Cell

Phone: 

Evening

Phone: 

Father’s

Name: SSN: Sponsor

(Yes/No): 

Address: 

Daytime

Phone: 

Cell

Phone: 

Evening

Phone: 
Birth | 8 

Birth: Personal Information (continued)

Sibling’s Name: Age:

Sibling’s Name: Age:

Sibling’s Name: Age:

Other Household Members:

Language Spoken at Home:

Other Languages:
Birth | 9 

Birth: Birth History

Birth Location: 

Complications During Birth: 

Neonatal Hospitalization: 

Diagnosis:

MM/DD/YY Diagnosis

Surgeries:

MM/DD/YY Procedure Results

Note: Space is provide on the following page for any additional comments concerning Diagnosis and Surgeries.
Birth | 10 

Birth: Birth History (Continued)

Comments regarding diagnosis:

Comments regarding surgeries:
Routines and Preferences | 11 

■■

Routines and Preferences

Daily Routine 

If you have a plan of care for your family member, please insert it here� 

Daily treatments (e�g�, respiratory treatment, 02, vent, trach, g-tube, etc�) include:

Vital signs:

Respiratory treatment:

Trach/g-tube/other care:
Routines and Preferences | 12 

Routines and Preferences: Daily Routine (continued) 

Bowel/bladder routine:

Adaptive equipment (W/C, braces, splints, speech devices):

Medications:

Medication Dose When to Administer
Routines and Preferences | 13 

Routines and Preferences: Describe a Typical Day

Provide a description of your family member’s daily routine throughout the week including when he or

she wakes up and goes to sleep, takes naps, has mealtimes, when medications should be taken, bathing,

and grooming information:

Day Routine

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday
Routines and Preferences | 14 

Routines and Preferences: Daily Schedule and Support Providers

Use this table to track your family member’s daily schedule and associated care providers. Identify

particular activities (e.g., sleeping, eating, working, attending therapy) and who is responsible for your

family member during that time (e.g., family member, friend, job coach, speech therapist).

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday

8–8:30am

8:30–9am 

9–9:30am

9:30–10am

10–10:30am

10:30–11am

11–11:30am

11:30–12pm

12–12:30pm

12:30–1pm

1–1:30pm

1:30–2pm

2–2:30pm

2:30–3pm

3–3:30pm

3:30–4pm

4–4:30pm

4:30–5pm

5–5:30pm

5:30–6pm

6–6:30pm

6:30–7pm

7–7:30pm

7:30–8pm

8–8:30pm

8:30–9pm
Routines and Preferences | 15 

Routines and Preferences: Personal Care

List tasks that your family member is able to do independently (e.g., eating, bathing, 

toileting, dressing, moving):

List tasks for which your family member requires assistance (e.g., eating, bathing, 

toileting, dressing, moving) and the kind of assistance that should be provided:

Task Assistance Required

List tasks that your family member may try to do independently that could endanger 

him or her: 

List other information related to personal care that would be helpful to those providing 

care for your family member (e.g., shoe and clothing sizes, menstrual cycle):
Routines and Preferences 16 |

Routines and Preferences: Food Preferences

List foods that your family member particularly enjoys and or dislikes: 

Likes Dislikes

Typical daily diet: 

Meal Preferred Foods/Drinks

Breakfast

Lunch

Dinner

Snack
Routines and Preferences 17 |

Routines and Preferences: Food Preferences (continued)

Favorite restaurants and preferred meals: 

Restaurant Preferred Meals Additional Information (e.g., favorite server, 

routines before or after the meal)

Average total caloric intake/day: 

Average total water/day: 

Food taken by: Mouth G-tube GJ tube NG NJ

Note: It might be helpful to make a video for care providers of how your family member eats/takes in nourishment and any

routines surrounding meals.

Size of tube: 

Uses ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ to communicate

wants and needs (e.g., picture book or communication board). If necessary, briefly describe how to use the

communication device with your family member.

Note: It might be helpful to make a video for care providers of your family member using his or her communication device.
Routines and Preferences | 18 

Routines and Preferences: Food and Other Allergies

Allergies (e.g., food, medications, materials):

Allergen Allergic Reaction How To Respond/

Who to Contact
Routines and Preferences | 19 

Routines and Preferences: Diet Tracking Form

Week of: Weight: 

Date Checked: 

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

6am

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm
Routines and Preferences | 20 

Routines and Preferences: Behavior Help

Provide a description of any behavior problems that commonly arises with your family member. Describe 

anything that might trigger the negative behavior (e.g., introduced to a new person or a new place or 

otherwise placed in an uncomfortable situation) and how a caregiver should respond to the behavior and 

address it. Provide the name and description of techniques or things that are helpful and where they can 

be located (e.g., afraid of thunderstorms — use headphones and music to help block out the noise).

What Often Occurs Before Behavior Problem/ How to Respond/

Behavior Problem Impact on Family Member Successful Interventions

1.

2.

3.
Routines and Preferences | 21 

Routines and Preferences: Leisure Activities and Social Experiences

List any leisure activities that your family member particularly enjoys or dislikes.

TV shows/movies/video games:

Likes Dislikes

Music/books:

Likes Dislikes
Routines and Preferences | 22 

Routines and Preferences: Leisure Activities and Social 

Experiences (continued)

Hobbies/activities in the home:

Likes Dislikes

Leisure activities/clubs outside the home:

Name of Club: Name of Club: 

Contact Person: Contact Person: 

Phone: Phone: 

How Often: How Often: 

Other Notes: Other Notes: 
Routines and Preferences | 23 

Routines and Preferences: Leisure Activities and Social 

Experiences (continued)

Vacation/traveling:

Likes Dislikes

Desired places to visit in the future:

Special interests: 

Situations that make your family member uncomfortable:
Routines and Preferences | 24 

Routines and Preferences: Pets and Service Animals

Include service animal’s license and shot record here.

Pet(s):

Pet’s Name Type of Animal Notes About Pet Care

Any additional notes about the pet(s):

Service animal(s):

Service 

Animal’s Name Type of Animal How the Animal Helps Me

Notes About Service 

Animal Care

Any additional notes about the service animal:
School | 25 

■■

School

School History

Year School Teacher School Nurse Phone #
School | 26 

School: School Evaluations and Discipline

Include any evaluations here (e.g., school district evaluations, independent evaluations).

Note any disciplinary actions received at school (e.g., suspension, detention) and the 

reason for the action.
School | 27 

School: Education Plans 

Please attach copy of Individualized Education Program (IEP) or Individual Habilitation Plan (IHP).

School information:

School Name: School Phone: 

Teacher: School Nurse: 

School OT: Phone: Frequency: 

School PT: Phone: Frequency: 

School ST: Phone: Frequency:
Employment | 28 

■ Employment

Current Employment and Employment History

Current place of employment:

Contact person: 

Address: 

Phone: 

Hours/days worked:

Job Coach:

Name: 

Address: 

Email: 

Phone: 

Fax: 

Employment history:
Employment | 29 

Employment: Vocational Experience

List work potential below. What kinds of employment support, if any, is received and 

from which agencies?

List capabilities, skill level, and other pursuable opportunities.
Medical Information | 30 

■■

Medical Information

Medication History Tracking Sheet

Start

Date

Stop 

Date

Medication 

(brand/generic)

Prescribed

 by

Dose/ 

Route

Time 

Given

Reason for 

Medication

Briefly note any medication allergies (see■the■Allergies■chart■on■page■18 for more information):■
Medical Information | 31 

Medical Information: Pharmacist

Name: Phone: 

Email: 

Address: 

Name: Phone: 

Email: 

Address: 

Name: Phone: 

Email: 

Address: 

Name: Phone: 

Email: 

Address: 
Medical Information | 32 

Medical Information: Hospital Tracker

Date Hospital Reason for Admission Notes
Medical Information | 33 

Medical Information: Lab Work/Tests

Date Test Result Comments
Medical Information | 34 

Medical Information: Immunization Records

Include the date when the listed immunizations were received. Use the remaining blocks at the bottom

as necessary.

DtaP 1. 2. 3. 4. 5.

DT 1. 2.

Polio 1. 2. 3. 4.

HIB 1. 2. 3. 4.

Prevnar 1. 2. 3. 4.

MMR 1. 2.

Varicella 1.

HBV 1. 2. 3.

TB

Flu

Other

Other

Other

Below, note any reactions to shots/immunizations.

Shot/Immunization Reaction Treatment
Medical Information | 35 

Medical Information: Current Medical Diagnoses

Date Diagnosis Notes
Medical Information | 36 

Medical Information: Appointment Log

Date Provider Reason Seen/Care Provided Next Appointment
Medical Information | 37 

Medical Information: Family Medical History

Check the box if one or more family members have had one of these health conditions and note how they

are related.

Condition Relative Condition Relative

Cardiac Diabetes

 Hypertension Blood

Renal Ear

 Tuberculosis Thyroid

 Gastro-intestinal Vision

 Cancer Psychological

 Allergy Auto Immune

 Orthopedic 

 Lung 

Additional family information:

Name Date of Birth Health

Mother: 

Father: 

Sibling: 

Sibling: 

Sibling: 

Sibling: 

Sibling: 
Medical Information | 38 

Medical Information: Equipment/Supplies

Type of Equipment/

Supplies

Prescribed

by

Reason

Prescribed

Date 

Started

Date 

Ended

Vendor 

Phone/Fax
Medical Information 39 |

Medical Information: Equipment/Supplies (continued)

List any other relevant notes regarding any equipment used or needed.
Social Worker: 

Address: 

Email: Phone: Date of First Visit: 

Speech Therapist: 

Address: 

Email: Phone: Date of First Visit: 

Occupational Therapist: 

Address: 

Email: Phone: Date of First Visit: 

Specialist: Specialty: 

Address: 

Email: Phone: Fax: 

Specialist: Specialty: 

Address: 

Email: Phone: Fax: 

Service Providers | 40 

■ Service Providers

Provider Information
Service Providers | 41 

Service Providers: Outpatient Therapy

Therapy: Therapist:

Address: 

Email: Phone: Frequency:

Therapy: Therapist:

Address: 

Email: Phone: Frequency:

Therapy: Therapist:

Address: 

Email: Phone: Frequency:
Service Providers | 42 

Service Providers: Case Manager(s)

Case Manager: Agency: 

Address: 

Email: Phone: Fax: 

Please attach the plan of care provided by the Case Manager.

Notes:

Case Manager: Agency: 

Address: 

Email: Phone: Fax: 

Please attach the plan of care provided by the Case Manager.

Notes:

Case Manager: Agency: 

Address: 

Email: Phone: Fax: 

Please attach the plan of care provided by the Case Manager.

Notes:
Service Providers | 43 

Service Providers: Transportation (To and From Medical 

Therapy Appointments)

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 
Service Providers 44 |

Service Providers: Appointment Log

Date Provider Reason Seen/Care Provided Next Appointment
Support | 45 

■ Support

Family Support Resources

Exceptional Family Member Program Point of Contact: 

Note: To locate an EFMP service provider in your area visit, www.militaryinstallations.dod.mil.

Contact Person:

Address: 

Email: Phone: Fax: 

Parent Group:

Contact Person:

Address: 

Email: Phone: Fax: 

Religious Organization:

Contact Person:

Address: 

Email: Phone: Fax: 

Service Organization:

Contact Person:

Address: 

Email: Phone: Fax: 

Counseling Services:

Contact Person:

Address: 

Email: Phone: Fax: 
Support | 46 

Support: School Support

School: Start Date: 

Address: 

Phone: Fax: 

Contact Person/Title: 

Email: Phone: Fax: 

Contact Person/Title: 

Email: Phone: Fax: 
Support | 47 

Support: Respite Care

Respite Care Provider: Start Date: 

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 

Respite Care Provider: Start Date: 

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 

Respite Care Provider: Start Date: 

Contact Person: 

Agency: 

Address: 

Email: Phone: Fax: 

NOTE: If this care is to be covered by TRICARE, is the provider a TRICARE authorized provider? Has the Managed Care

Support Contractor authorized this respite care? Keep a copy of your respite care applications and any related documentation

in this section.
Support 48 |

Support: Advocates

List individuals, advocates, and/or service providers who are important to your family 

member’s well-being and are not otherwise listed in this document:

Name: 

Address: 

Email: Phone: Fax: 

Note what he or she does for or with your family member:

Name: 

Address: 

Email: Phone: Fax: 

Note what he or she does for or with your family member:

Name: 

Address: 

Email: Phone: Fax: 

Note what he or she does for or with your family member:
www.tricare.mil/contactus

TRICARE Regional Office (TRO): 

Address: 

City: State: Zip: 

Phone: Email: 

TRICARE Service Center: 

Address: 

City: State: Zip: 

Phone: Email: 

Beneficiary Counseling and Assistance Coordinator (BCAC): 

Address: 

City: State: Zip: 

Phone: Email: 

Debt Collections Assistance Officer (DCAO): 

Address: 

City: State: Zip: 

Phone: Email: 

Health Benefits and Insurance | 49 

■ Health Benefits and Insurance

TRICARE

Use this link to help find a local TRICARE Service Center (TSC):
Health Benefits and Insurance | 50 

Health Benefits and Insurance: TRICARE Dental Program

Use this website to find information regarding basic dental program benefits, the address for filing claims,

enrollment information, and a directory of network dentists:

www.tricaredentalprogram.com/tdptws/home.jsp

Dentist Name: 

Address: 

City: State: Zip: 

Phone: Email: 

Orthodontist: 

Address: 

City: State: Zip: 

Phone: Email: 

Note: On July 1, 2007, TRICARE implemented coverage for anesthesia services and associated costs for dental treatment

for beneficiaries with developmental, mental, or physical disabilities, and children age five and under. The services require

preauthorization through the regional TRICARE contractors (www.tricare.mil/mybenefit). The change in this benefit

does not provide coverage for the actual dental care services. Coverage for dental care services is available through the

TRICARE Dental Program and the TRICARE Retiree Dental Program.
Health Benefits and Insurance | 51 

Health Benefits and Insurance: Insurance Information

Please note all other insurance providers.

Name of Other Insurance: 

Policy Number: 

Contact Person/Title: 

Address: 

Email: Phone: Fax: 

Case Manager: 

Email: Phone: Fax: 

Name of Other Insurance: 

Policy Number: 

Contact Person/Title: 

Address: 

Email: Phone: Fax: 

Case Manager: 

Email: Phone: Fax: 

Name of Other Insurance: 

Policy Number: 

Contact Person/Title: 

Address: 

Email: Phone: Fax: 

Case Manager: 

Email: Phone: Fax: 
Health Benefits and Insurance | 52 

Health Benefits and Insurance: Medical Bill Tracker

Date Provider Amount

Billed

Amount

Allowed

Amount

Paid

Paid by

Health

Insurance

Family

Owes

Debt

Paid
Transitioning/Moving | 53 

■■

Transitioning/Moving

Transitioning/Moving Checklist

Use this checklist to help organize your move� Add to it to meet your specific needs�

Arrangements

■■Service■animal■travel■and■requirements

Emergency■telephone■numbers■(relief■societies,■American■Red■Cross,■physician)

Accessible■lodging■arrangements

Power■for■medical■equipment■while■traveling

Vehicle■trailer■for■transporting■necessary■support■equipment■and■supplies

Air Travel Arrangements

Notice■for■special■accommodation■for■air■travel■(forty-eight■hours■notice)

Assistance■with■boarding,■deplaning,■and■making■connections

Additional■fee■for■oxygen

Be■prepared■to■provide■battery■(dry■and■wet■cell)■information

On-board■wheelchairs

Record■height,■width,■and■depth■of■wheelchair

Accessible■vehicle■transportation■at■the■destination

Preparation for Packing

Prepare■first■aid■kit

Prepare■a■travel■entertainment■backpack■

Locate■medical■documents■to■hand-carry

Locate■dental■documents■to■hand-carry

Locate■special■education■Individualized■Education■Program■(IEP)■paperwork■to■hand-carry

Locate■military■and■medic■alert■ID■cards

Locate■medical■supplies

Medications■(try■to■have■enough■medications■to■last■you■for■the■next■three■months)

Packing

Medical■supplies

Medications

Medical■equipment,■e.g.,■nebulizer,■portable■suction■machine

School■documents

IEP■paperwork

Section■504

Teacher■observations/recommendations
Transitioning/Moving | 54 

Packing (continued) 

Legal documents

Special bedding

Positioning or body support cushions

Child/adult diapers and cleansing cloths

Washcloths, towels, and extra sheets if needed

Garbage bags for soiled diapers and cloths

First aid kit

Special food items

Assistive technology devices and battery chargers

Important phone numbers

Arrival checklist

Military IDs

Handicapped parking placard

Medical Alert jewelry or cards

Bath chair (remember it may take a few weeks for you to receive your household goods)

Hoyer Lift

Wheelchair or scooter

Wheelchair tray

Wheelchair battery charger

Wheelchair transfer board

Weather protection

Eating and drinking utensils

Bibs

Service animal rabies tag

Service animal license

Service animal food and bowls

Medications, if necessary

Disposable bags

Favorite toys for service animal

Extra harness

■ ■ ■ ■ ■ ■ ■
Transitioning/Moving | 55 

Transitioning/Moving: Transportation When Moving

Note which forms of transportation are NOT acceptable for your family member when 

moving and provide a brief explanation:

Note any lodging-related needs when traveling with your family member (e.g., must be 

wheelchair accessible (to include the shower stall), TTY/TDD telephone):

Other notes regarding transitioning/moving:

NOTE: Speak with your installation Household Goods/Transportation Office regarding the shipment of required medically

necessary equipment. Required medical equipment must be certified by an appropriate Uniformed Services health care

provider as necessary for the medical treatment of the authorized family member.
Planning Ahead 56 |

■ Planning Ahead

Introduction

It■might■be■difficult■to■consider■that,■at■some■point,■illness■may■prevent■you■from■continuing■to■

provide■care■for■your■family■member.■It■is■even■harder■to■consider■that■your■family■member■may■outlive■

you.■Because■you■would■not■want■your■family■member’s■quality■of■life■to■be■affected■or■altered■in■any■

significant■way■it■is■important■to■legally■establish■the■level■of■care■you■would■like■to■continue■for■your■

family■member■in■your■absence.

This■section■is■intended■to■help■you■organize■information■and■plans■in■the■event■that■someone■would■have■

to■take■over■your■care■giving■responsibilities.■It■can■be■used■to■facilitate■discussion■among■your■family■

members■or■to■organize■your■own■thoughts.
Planning Ahead | 57 

Planning Ahead: Advance Directive Quick Glance

This is not an Advance Directive and should not be used as a legally binding document. Rather, this page 

provides you with some things to consider when developing an Advance Directive. Be sure to include a 

copy of the official Advance Directive with this sheet in the SCOR.

Have you spoken about your wishes with your:

Family Physician(s) Friends 

Clergy Attorney Case Manager

Does the person(s) you have appointed to make 

decisions on your behalf understand your wishes? 

Yes No

Have you spoken to this person about your current 

and future medical care? 

Yes No

Is the person(s) you have appointed to make 

decisions on your behalf aware of your “Do Not 

Resuscitate (DNR) Order” if you have one?

Yes No

Have you given a copy of your completed and 

signed advanced directive to the person(s) you have 

appointed to make decisions on your behalf?

Yes No

Contact Information

The Person You Have Appointed To Make Decisions On Your Behalf

Name: 

Address: 

Email: 

All Telephone Numbers: 

Alternate Person’s Contact Information (if applicable)

Name: 

Address: 

Email: 

All Telephone Numbers: 
Planning Ahead | 58 

Contact Information (continued)

Attending Physician’s Contact Information

Name: 

Address: 

Email: 

All Telephone Numbers: 

Fax: 

Secondary Physician’s Contact Information (If available):

Name: 

Address: 

Email: 

All Telephone Numbers: 

Fax: 

Additional Resource: 

U.S. Living Will Registry (www.uslivingwillregistry.com/forms.shtm): This website provides

advanced directive information for each state.
Planning Ahead | 59 

Planning Ahead: Family Information

Spouse’s Name: Email: 

Date of Birth: 

Address: 

Phone Number: 

Child’s Name: Email: 

Child’s Spouse:

Date of Birth: 

Address: 

Phone Number: 

Child’s Name: Email: 

Child’s Spouse:

Date of Birth: 

Address: 

Phone Number: 

Child’s Name: Email: 

Child’s Spouse:

Date of Birth: 

Address: 

Phone Number: 
Planning Ahead | 60 

Planning Ahead: Family Information (continued)

Sibling’s Name: Email: 

Sibling’s Spouse:

Date of Birth: 

Address: 

Phone Number: 

Sibling’s Name: Email: 

Sibling’s Spouse:

Date of Birth: 

Address: 

Phone Number: 

Sibling’s Name: Email: 

Sibling’s Spouse:

Date of Birth: 

Address: 

Phone Number: 

Sibling’s Name: Email: 

Sibling’s Spouse:

Date of Birth: 

Address: 

Phone Number: 
Planning Ahead 61 |

Planning Ahead: Other Relatives

If you have established a Special Needs Trust for your family member, note whether other family

members have been told about it to ensure that they are aware of the option of leaving money or

contributing to the Trust.

Relative’s Name: 

Address: 

Phone: Email: 

Notified: Yes No

Date

Notified: 

Method of

Notification: 

Relative’s Name: 

Address: 

Phone: Email: 

Notified: Yes No

Date

Notified: 

Method of

Notification: 

Relative’s Name: 

Address: 

Phone: Email: 

Notified: Yes No

Date

Notified: 

Method of

Notification: 

Relative’s Name: 

Address: 

Phone: Email: 

Notified: Yes No

Date

Notified: 

Method of

Notification: 
Planning Ahead | 62 

Planning Ahead: Living Arrangements for Your Family Member in 

the Future

Where and in what type of situation would the family member prefer to live? Alone or with roommates?

What neighborhood? How much supervision will be necessary?

First Choice of Future Residential Provider

Name: 

Phone Number: 

Second Choice of Future Residential Provider

Name: 

Phone Number: 

If currently in a supported living environment, list the following information:

Home Manager Name: 

Phone Number: 

Case Manager Name: 

Phone Number: 
Planning Ahead | 63 

Planning Ahead: Financial Information

BANK

Company: Phone: 

Branch Location: 

Checking Account Number: Savings Account Number: Safety Deposit Box: 

Contact Person/Title: 

Email: Phone: Fax: 

BANK 

Company: Phone: 

Branch Location: 

Checking Account Number: Savings Account Number: Safety Deposit Box: 

Contact Person/Title: 

Email: Phone: Fax: 

LIFE INSURANCE

Company: Phone: 

Policy Number: 

Where Policy is Located: 

Insurance Company Location: 

Contact Person/Title: 

Email: Phone: Fax: 
Planning Ahead | 64 

Planning Ahead: Financial Information (continued)

LIFE INSURANCE

Company: Phone: 

Policy Number: 

Where Policy is Located: 

Insurance Company Location: 

Contact Person/Title: 

Email: Phone: Fax: 

BURIAL POLICY

Funeral Home: Phone: 

Cemetery: Phone: 

Policy Number: 

Where Policy is Located: 

Contact Person/Title: 

Email: Phone: Fax: 

Specific Instructions: 
Planning Ahead | 65 

Planning Ahead: Supplemental Security Income (SSI) 

When the special needs family member turns eighteen years old, he or she can apply for Supplemental 

Security Income (SSI) at your local Social Security Office. SSI payments are provided as a provision of

Title XVI of the Social Security Act.

The following table was designed by the Social Security Administration (SSA) to help you keep track of

SSI and expenses.

Contact the Social Security Administration at 1-800-772-1213 to request form SSA-623.

Note: Form SSA-623 is not available online.

Income and Expenses Worksheet

Month and Year Amount of SSI 

Benefits Received

Expenses for food 

and housing

Expenses for clothing, 

medical/dental, 

personal items, 

recreation, misc.

TOTAL for 

report period

$ $ 

Put this figure on line 3B 

of the Form SSA-623

$ 

Put this figure on line 3C 

of the Form SSA-623

Show the amount of benefits you saved for the beneficiary, 

including any interest earned.

$ 

Put this figure on line 3D 

of the Form SSA-623
Planning Ahead 66 |

Planning Ahead: Guardianship

Letters of Guardianship have been approved by:

Judge: Date: 

Approved Guardian’s Name: 

Relationship: 

Address: 

Phone: Fax: 

Approved Successor Guardian’s Name: 

Relationship: 

Address: 

Phone: Fax: 

Approved Successor Guardian’s Name: 

Relationship: 

Address: 

Phone: Fax: 

Guardian Ad Litem’s Name: 

Email: 

Address: 

Phone: Fax: 

Note: Keep a copy of all relevant court documents in this section.
Planning Ahead | 67 

Planning Ahead: Guardianship (continued)

If a guardian has not yet been appointed, list in order of preference the people who you would like to serve

as guardian, should guardianship prove necessary in the future. Include name, address, phone number,

and the person’s relationship to the special needs family member.

Name Address Phone Number Relationship
Other Resources | 68 

■ Other Resources

MilitaryHOMEFRONT: www.militaryhomefront.dod.mil

MilitaryHOMEFRONT is the official Department of Defense website for quality of life information and resources.

Sections tailored to meet the specific and unique needs of Leadership, Troops and Family Members, and Service

Providers, MilitaryHOMEFRONT provide current, reliable, and easily accessible information for the military

community. Whether you live the military lifestyle or support those who do, you’ll find what you need! Information

specific to special needs family members and the Exceptional Family Member Program (EFMP) can be found at

www.militaryhomefront.dod.mil/efm.

HOMEFRONTConnections: https://apps.mhf.dod.mil/homefrontconnections

HOMEFRONTConnections is a Department of Defense social networking environment designed for those

who are in the military, in a military family, or who support the military and their families. Within the password

protected site, group (or “Communities”) can share best practices, post pictures and videos, or just share

information about the work they are doing. Families can also use the site to meet each other or to establish online

family readiness groups.

Plan My Move: www.militaryhomefront.dod.mil/tf/movingandrelocation

Plan My Move, available through MilitaryHOMEFRONT, is a set of online organizational tools designed to make

frequent moves easier and less disruptive for service members and families.  Available tools include a customizable

calendar, to-do lists, departure and arrival checklists, installation overviews, and installation-specific information

on a number of topics, such as education, transportation, child care, and employment. This site is easy to use and

provides quick information and results.

Military OneSource: www.militaryonesource.com

Military OneSource provides information and resources to help balance work and family life. Consultants are

available twenty-four hours a day, seven days a week by phone, online, or via email offering personalized support to

any service or family member.

TRICARE: www.tricare.mil

The TRICARE website provides information about military health plans, military treatment facilities, and other

TRICARE resources.

Exceptional Family Member Program information by branch:

For branch specific EFMP information, visit www.militaryhomefront.dod.mil. Enter “EFMP” and your

branch of service in the search bar. For National Guard EFMP information visit, www.guardfamily.org.

RELEVANT FORMS

DD Form 2792, Exceptional Family Member Medical Summary can be found at www.dtic.mil/whs/directives/

infomgt/forms/forminfo/forminfopage2336.html.

DD Form 2792-1, Exceptional Family Member Special Education/Early Intervention Summary can be found at

www.dtic.mil/whs/directives/infomgt/forms/forminfo/forminfopage2581.html.
Other Resources | 69 

ACRONYM INDEX

Use the table below to list any acronyms that you may need to remember.

Acronym Meaning
Other Resources | 70 

ACRONYM INDEX (continued)

Acronym Meaning
■ Additional Notes
■ Additional Notes
■ Additional Notes
■■

Additional Notes

Created for you by the Department of Defense

Exceptional Family Member Program

Providing policy, tools, and resources to further enhance the quality of life of service members and their families.