Special Care Organizational Record

for Children with Special Health Care Needs SCOR
■ Table of Contents

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

In Case of an Emergency� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5

Birth� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8

All About Me� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12

School and Employment� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 26

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

Care Providers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 43

Support � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 47

Health Benefits and Insurance� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53

Transitioning/Moving� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 57

Estate/Future Plan� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 60

Other Resources� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 71
■

Introduction | 1 

Introduction

The■Special■Care■Organizational■Record■(SCOR)■for■Children■with■Special■Health■Care■Needs■is■

specifically■designed■as■an■organizing■tool■for■parents■with■children■with■special■health■care■needs.■It■is■

intended■to■help■track■and■organize■your■child’s■information■to■make■it■easier■for■someone■to■care■for■

your■child■in■your■absence.■The■SCOR■can■be■used■to■capture■a■variety■of■information,■including■your■

child’s■birth■history,■likes■and■dislikes,■medical■and■educational■information,■insurance,■and■step-bystep■action■plans■in■case■of■an■emergency.■While■the■SCOR■is■organized■into■different■sections,■you■are■

encouraged■to■reorganize■it■to■accommodate■your■needs.

Please■note■that■while■the■SCOR■provides■instructions■for■the■care■and■keep■of■your■child,■it■is■not■

legally■binding■in■any■way.■It■also■contains■private■information■such■as■Social■Security■numbers,■

medical■history/information,■and■insurance■information.■To■maintain■your■family’s■privacy,■keep■your■

SCOR■in■a■safe■place.

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.■You■can■order■a■hard■copy■from■Military■OneSource■by■

visiting■www.militaryonesource.com.

If■you■have■any■questions■or■comments■about■the■SCOR■for■Children■with■Special■Health■Care■Needs,■

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 Children with Special Health Care Needs Guide

What is the SCOR for Children with Special Health Care Needs?

The SCOR is an organizing tool for families who have children with special health care needs. It is 

designed to help you keep track of relevant information regarding your child’s health and care in the 

event that you are unable to provide the care yourself.

How can the SCOR help you?

In the process of caring for your child with special health needs, information and paperwork that must 

be readily accessible. The SCOR will help you organize 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 your 

child’s care providers. 

Use the SCOR to

■ track changes in your child’s medicines or treatments;

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

■ prepare for appointments;

■ file information about your child’s health history; and

■ share new information with your child’s primary doctor, public health or school nurse, daycare staff, 

and others caring for your child. 

Some helpful hints for using your child’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 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 child’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 Children with Special Health Care Needs Guide (continued)

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

STEP 1: Gather information you already have. 

Gather■any■health■information■that■you■have■about■your■child.■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■for■tracking■your■child’s■health■and■care.■Once■you■

have■determined■what■you■need,■print■or■collect■only■those■pages■to■create■your■personalized■SCOR.

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■child?■Include■frequently■referenced■and■important■information■in■your■

portable■SCOR■and■store■additional,■less■critical■information■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■for■you■and■your■child.■If■you■downloaded■and■

printed■the■SCOR,■here■are■some■supplies■that■may■help:

■■ 3-ring■binder■or■large■accordion■envelope■to■hold■papers■securely■(provided■by■Military■OneSource■

if■ordered■from■the■website)

■■ 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■child’s■medical■history/information,■it■is■not■

intended■to■replace■official■medical■records.

■■ The■SCOR■is■not■legally■binding■in■any■way.■It■is■intended■to■provide■a■place■to■start■thinking■about■the■

care■your■child■would■receive■if■you■were■no■longer■able■to■provide■it.■However,■you■need■to■go■through■

the■proper■legal■protocol■to■make■legally■binding■decisions.■

■■ The■SCOR■contains■private■information■(e.g.,■Social■Security■numbers,■insurance■information,■

medical■history).■It■is■imperative■that■you■keep■it■in■a■safe■place.
Introduction | 4 

Resources

The Department of Defense Special Needs Parent Tool Kit Birth to 18 was designed to provide 

information for military families with children with special health care needs. The Tool Kit provides 

information regarding the services and support that are available to these families, as well as how to use 

them. The modules of the Tool Kit may provide you with additional information for your child’s SCOR. 

Below, SCOR sections are listed next to related Special Needs Parent Tool Kit module information.

To access the Special Needs Parent Tool Kit, visit the Special Needs/EFMP section of the 

MilitaryHOMEFRONT website at www.militaryhomefront.dod.mil/tf/efmp under “ToolBox.”

SCOR Section Corresponding Module of 

Special Needs Parent Tool Kit

Birth, All About Me, Support Module 1: Birth to Age Three

School and Employment

Module 2: 

review the 

end of the 

Special Education (Please also 

Records and Tools section at the 

Toolkit.)

Health Benefits and Insurance Module 3: Health Benefits

Transitioning/Moving, In Case of 

Emergency, Estate/Future Plan 

an Module 4: Families in Transition 

Support, Child Advocacy Module 5: Advocating for your Child 

Other Resources/Websites Module 6: Resources and Support
In Case of an Emergency | 5 

■In Case of an Emergency

Emergency Quick Glance

Name:

Date of Birth: Blood Type:

Address:

Phone:

Diagnosis(es): (For more on diagnoses, refer to the “Current Medical Diagnoses” sheet in 

the Medical Information Section.)

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 | 6 

Current medications: (For more on medications, refer 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, refer to the “Food and Other Allergies” sheet in the All 

About Me Section.)

Allergen Allergic Reaction How To Respond
In Case of an Emergency | 7 

In Case of an Emergency: Emergency Plan

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

should be handled (e.g., if your child is epileptic and has a seizure or your child 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 | 8 

■ 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:

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 | 9 

Birth: Personal Information (continued)

Sibling’s Name: Date of Birth:

Sibling’s Name: Date of Birth:

Sibling’s Name: Date of Birth:

Other Household Members:

Language Spoken at Home:

Other Languages:
Birth | 10 

Birth: Birth History

Birth Location: 

Complications During Birth: 

Neonatal Hospitalization: 

Diagnosis(es):

MM/DD/YY Diagnosis(es)

Surgical Procedures:

MM/DD/YY Surgical Procedures Results

Note: Space is provided on the following page for any additional comments concerning Diagnosis and Surgeries. Include a 

copy of the Individualized Family Service Plan (IFSP) in this section.
Birth 11 |

Birth: Birth History (Continued)

Comments regarding diagnosis(es):

Comments regarding surgical procedures:
All About Me | 12 

■ All About Me

Watch me Grow!

Date Age Height Weight Head 

Circumference

Major Developmental Milestones 

(e.g., crawls, talks, walks)
All About Me | 13 

All About Me: Daily Routine 

If you have a plan of care, please insert it here.

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

Vital signs:

Respiratory treatment:
All About Me | 14 

All About Me: Daily Routine (continued) 

Bowel/bladder routine:

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

Medications:

Medication Dose When to Administer
All About Me | 15 

All About Me: Describe a Typical Day

Provide a description of your child’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, as well as bathing and

grooming information:

Day Routine

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday
All About Me | 16 

All About Me: Personal Care

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

toileting, dressing):

List tasks for which your child requires assistance (e.g., eating, bathing, toileting, 

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

List tasks that your child 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 child (e.g., shoe and clothing sizes, menstrual cycle):
All About Me | 17 

All About Me: Food Preferences

List foods that your child particularly enjoys and/or dislikes: 

Likes Dislikes

Typical daily diet: 

Meal Preferred Foods/Drinks

Breakfast

Lunch

Dinner

Snack
All About Me | 18 

All About Me: 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 

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

surrounding meals.

NJ

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 child.

Note: It might be helpful to make a video for care providers of your child using his or her communication device.
All About Me 19 |

All About Me: Food and Other Allergies

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

Allergen Allergic Reaction How To Respond/

Who to Contact
All About Me 20 |

All About Me: 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
All About Me | 21 

All About Me: Behavior Help

What consistent approach has worked best when parents/caregivers have not been available during

difficult transition periods? List typical interventions that have worked. Provide names and

descriptions of techniques or things that are helpful and where they can be located. (Example: afraid of

thunderstorms, use headphones to help block out the noise)

Behavioral Interventions: 

Things that help to calm your child:
All About Me | 22 

All About Me: Leisure Activities and Social Experiences

List any leisure activities that your child particularly enjoys or dislikes.

TV shows/movies/video games:

Likes Dislikes

Music/books:

Likes Dislikes
All About Me | 23 

All About Me: 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: 
All About Me | 24 

All About Me: Leisure Activities and Social Experiences (continued)

Vacation/traveling:

Likes Dislikes

Desired places to visit in the future:

Special interests: 

Situations that make your child uncomfortable:
All About Me | 25 

All About Me: 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 and Employment

School and Employment 26 |

School History

Year School Contact Person School Nurse Phone #
School and Employment | 27 

School and Employment: School Evaluations and Discipline

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

Year School Evaluation Comments

List any disciplinary actions received at school (e.g., suspension, detention).

Year School Disciplinary Action Reason
School and Employment | 28 

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:

Vocational Experience

List work potential below. What 

from which agencies?

kinds of employment support, if any, is received and 

Year Company Supervisor Contact Comments
School and Employment | 29 

Vocational Experience (continued)

List capabilities, skill level, and other pursuable opportunities.

Current Employment and Employment History

Current place of employment:

Contact person: 

Address: 

Phone: 

Hours/days worked:

Employment history:
■

Medical Information 30 |

Medical Information

Medication History Tracking Sheet

Start

Date

Stop 

Date (b

Medication 

rand/generic)

Prescribed

 by

Dose/ 

Route

Time 

Given

Reason for 

Medication

Briefly note any medication allergies (refer to the Allergies chart on page 19 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: Doctor Visits

Date Seen By Notes/Updates from Visit
Medical Information 33 |

Medical Information: Hospital Tracker

Date Hospital Reason for Admission Notes
Medical Information | 34 

Medical Information: Lab Work/Tests

Date Test Result Comments
Medical Information | 35 

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 36 |

Medical Information: Current Medical Diagnoses

Date Diagnosis Notes
Medical Information | 37 

Medical Information: Appointment Log

Date Provider Reason Seen/Care Provided Next Appointment
Medical Information | 38 

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 39 |

Medical Information: Equipment/Supplies

Type of Equipment/

Supplies

Prescribed

by

Reason

Prescribed

Date 

Started

Date 

Ended

Vendor 

Phone/Fax
Medical Information 40 |

Medical Information: Equipment/Supplies (continued)

List any equipment that your child has specifically received through the school. 

Include when it has to be returned and any other parameters regarding use of the 

equipment. A copy of the IEP can be beneficial in this section as well because you may 

be required to return assistive technology received through the school when you leave 

the school district:

Item School and Year Contact Due Date

List any other notes that you feel are relevant regarding any equipment your 

child needs: 
Medical Information | 41 

Medical Information: Medical Providers

Primary Care Manager (PCM):

Military Treatment Facility (MTF):

Address: 

Email: Phone: Fax:

Civilian Hospital: 

Address: 

Email: Phone: Fax:

Dentist:

Address: 

Email: Phone: Fax:

Nursing Agency: Contact Person:

Address: 

Email: Phone: Date of first visit:

# of hours approved: Day: Night: Weekend:
Medical Information | 42 

Medical Information: Medical Providers (continued) 

Nutritionist:

Address: 

Email: Phone: Date of first visit:

Physical Therapist:

Address: 

Email: Phone: Date of first visit:
Care Providers | 43 

■ Care Providers

Provider Information

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: 
Care Providers | 44 

Care Providers: Outpatient Therapy

Therapy: Therapist:

Address: 

Email: Phone: Frequency:

Therapy: Therapist:

Address: 

Email: Phone: Frequency:

Therapy: Therapist:

Address: 

Email: Phone: Frequency:
Care Providers | 45 

Care 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:
Care Providers | 46 

Care 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: 
Support | 47 

■ Support

Early Intervention Services

Developmental 

Center: Start Date:

Agency:

Address:

Email: Phone: Fax: 

Family Resources

Coordinator: Start Date:

Agency:

Address:

Email: Phone: Fax: 

Note: A copy of your Individual Family Services Plan can be kept here or in the “Birth” section.
Support | 48 

Support: Family Support Resources

Exceptional Family Member Program Point of Contact: 

Note: To locate an EFMP service provider in your area visit, www.militaryinstallation.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 | 49 

Support: Child Care Support

Child Care Provider: Start Date: 

Contact Person:

Address: 

Email: Phone: Fax: 

Child Care Provider: Start Date: 

Contact Person:

Address: 

Email: Phone: Fax: 

Child Care Provider: Start Date: 

Contact Person:

Address: 

Email: Phone: Fax: 

Note: Include any relevant child care documents (such as the SNRT paperwork) in this section
Support | 50 

Support: School Support

School: Start Date: 

Address: 

Phone: Fax: 

Contact Person/Title: 

Email: Phone: Fax: 

Contact Person/Title: 

Email: Phone: Fax: 
Support | 51 

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 52 |

Support: Child Advocates

List individuals, advocates, and/or service providers who are important to your child’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 child:

Name: 

Address: 

Email: Phone: Fax: 

Note what he or she does for or with your child:

Name: 

Address: 

Email: Phone: Fax: 

Note what he or she does for or with your child:
Health Benefits and Insurance | 53 

■■

Health Benefits and Insurance

TRICARE

Use■this■link■to■help■find■a■local■TRICARE■Service■Center■(TSC):

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 | 54 

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 | 55 

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 | 56 

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 | 57 

■ 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 | 58 

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 (see Plan my Move calendar at http://apps.mhf.dod.mil/pls/psgprod/f?p=MHF:RELO:0

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 | 59 

Transitioning/Moving: Transportation When Moving

Note which forms of transportation are NOT acceptable for your child when moving and 

provide a brief explanation:

Note any lodging-related needs when traveling with your child (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.
■

Estate/Future Plan | 60 

Estate/Future Plan

Letter of Intent

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

provide care for your child. It is even harder to consider that your child may outlive you. You have 

provided a level of care that you would want to ensure continued.

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.
Estate/Future Plan | 61 

Estate/Future Plan: Family Information

Mother’s Name: Maiden Name:

SSN:

Address:

Phone numbers:

Email:

Father’s Name:

SSN:

Address:

Phone numbers:

Email:

Sibling’s Name:

Sibling’s Spouse:

Address:

Phone numbers:

Email:
Estate/Future Plan | 62 

Estate/Future Plan: Family Information (continued)

Siblings’s Name:

Sibling’s Spouse:

Address:

Phone numbers:

Email:

Siblings’s Name:

Sibling’s Spouse:

Address:

Phone numbers:

Email:

Siblings’s Name:

Sibling’s Spouse:

Address:

Phone numbers:

Email:
Estate/Future Plan 63 |

Estate/Future Plan: Informing Other Family Members

If you have established a Special Needs Trust for your child, 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: 
Estate/Future Plan | 64 

Estate/Future Plan: Living Arrangements for Your Child in 

the Future

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

Which 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: 
Estate/Future Plan | 65 

Estate/Future Plan: 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: 
Estate/Future Plan | 66 

Estate/Future Plan: 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: 
Estate/Future Plan 67 |

Estate/Future Plan: 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.
Estate/Future Plan | 68 

Estate/Future Plan: 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
Estate/Future Plan | 69 

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 Have you spoken to this person about your current 

decisions on your behalf understand your wishes? and future medical care? 

Yes No Yes No

Is the person(s) you have appointed to make Have you given a copy of your completed and 

decisions on your behalf aware of your “Do Not signed advanced directive to the person(s) you have 

Resuscitate (DNR) Order” if you have one? appointed to make decisions on your behalf?

Yes No 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: 
Estate/Future Plan | 70 

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 

Directive information for 

(www.uslivingwillregistry.com/forms.shtm): 

each state.

This website provides Advance 
Other Resources 71 |

■ 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■

http://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 links by branch:

Army |

 Marine Corps | Navy | Air Force | Coast Guard | National Guard

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 | 72 

ACRONYM INDEX

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

Acronym Meaning
Other Resources | 73 

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.