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NC DMH 5-72-19: First Examination for IVC

In North Carolina involuntary commitment (IVC) cases, the first-level examination of the respondent is recorded on DMH 5-72-19. A clinician meets it when examining the respondent in person at a facility or by telemedicine. The examiner decides whether the respondent meets criteria for inpatient, outpatient or substance abuse commitment, completes a health screening, and recommends a disposition that is sent to the clerk of superior court.

Who completes it

A commitment examiner completes the whole form: a physician, an eligible psychologist, or a health or mental health professional certified by DHHS (PA, master's-level NP, LCSW, LCMHC, LMFT, or LCAS for substance abuse evaluations only). Vital signs may be taken by another person, who signs that part.

Submitting and payment

How to submit it
Copies go to the clerk of superior court, the 24-hour facility or proposed outpatient provider and the area facility; if the clerk cannot receive them within 48 hours, the examiner phones in the findings. Session Law 2023-103 requires electronic filing of IVC documents through eCourts, live in all 100 counties since October 13, 2025.

Good to know

  • The health screening lists red flags, such as chest pain, suspected overdose or head trauma, that send the respondent to an emergency department, and others that require a medical provider consult within one hour.
  • A medical evaluation by an MD, DO, PA or NP can replace the health screening if the examiner checks the box and signs.
  • For telemedicine exams, the examiner certifies the results match an in-person exam or states that a face-to-face evaluation is needed.
  • Examiners other than physicians and eligible psychologists must hold DHHS first-level commitment examiner certification before signing.

Get the official form

Download the current version from the source each time; forms change without notice.

First Examination for Involuntary Commitment

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can complete the NC first examination for involuntary commitment?

A physician, an eligible psychologist, or a professional certified by DHHS as a first-level commitment examiner, such as a PA, master's-level NP, LCSW, LCMHC or LMFT. An LCAS may examine for substance abuse commitment only.

Can the DMH 5-72-19 exam be done by telemedicine?

Yes. The form has a box for telemedicine examinations, and the examiner must certify to a reasonable degree of medical certainty that the results were the same as if they had been personally present, or state that the respondent needs a face-to-face evaluation.

Can the DMH 5-72-19 still be faxed to the clerk?

Not in eCourts counties. NCDHHS states that Session Law 2023-103 requires electronic filing of IVC documents, that all 100 counties launched eCourts by October 13, 2025, and that fax and secure electronic transmission are no longer accepted there.