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NC DHHS 3987: Medical Exemption Statement Form

North Carolina physicians use this two-page statement to certify a medical exemption from required immunizations when the patient has a contraindication adopted by the NC Commission for Public Health, which follows ACIP. The physician checks the listed contraindications by vaccine and states when the exemption ends. Agencies that require proof of immunization can accept it without approval from the State Health Director.

Who completes it

A physician (MD or DO) licensed to practice medicine in North Carolina completes and signs the form, which also records the patient, parent or guardian, county and the child care, school, college or university.

Submitting and payment

How to submit it
Attach the most current immunization record, keep a copy in the medical record, and return the original to the person who asked for it, who gives it to the school, child care center or program. It is not sent to the state.

Good to know

  • Only contraindications printed on the form qualify, such as a severe allergic reaction to a prior dose or component, or severe immunodeficiency for MMR and varicella. Anything else needs DHHS 3995.
  • Enter the date the exemption ends or how long it applies; the form asks for this instead of a permanent or temporary checkbox.
  • Covered vaccines are DTaP, Tdap, DT/Td, MMR, varicella, IPV, hepatitis B, Hib, PCV13 and MenACWY, each with its own contraindication list.
  • North Carolina has no religious exemption form: families write a statement with the person's name, date of birth and reason, without notarization, and give it to the school.

Get the official form

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

NC Medical Exemption Statement Form

Official pagePDF

Fill it with Vero

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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

Does DHHS 3987 need approval from the state?

No. The form states that it does not need to be submitted to the State Health Director and may be accepted by agencies that require proof of immunization. Only contraindications that are not listed on DHHS 3987 go to the State Health Director, using the Physician's Request for Medical Exemption, DHHS 3995.

Can a nurse practitioner sign the NC medical exemption form?

The form states that a physician (MD or DO) licensed to practice medicine in North Carolina must complete and sign it. NCDHHS repeats that the doctor must be licensed in North Carolina, so a statement signed by another type of clinician or an out-of-state physician does not meet the requirement.

What if a contraindication is not listed on DHHS 3987?

The physician submits DHHS 3995, the Physician's Request for Medical Exemption, to the State Health Director with supporting documentation such as clinic notes or labs. The State Health Director may grant or deny that request, unlike DHHS 3987, which certifies a listed contraindication directly.