When a North Carolina patient has a reason not to receive a required vaccine that is not among the contraindications listed on DHHS 3987, the physician uses this one-page request instead. It names each vaccine, describes the contraindication and proposes how long the exemption should apply. The State Health Director reviews it with the supporting records and may grant or deny it.
A physician (MD or DO) licensed in North Carolina completes and signs the whole form, which records the patient, parent or guardian, home county and the child care, school, college or university.
Download the current version from the source each time; forms change without notice.
NC Physician's Request for Medical Exemption Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Use DHHS 3995 when the reason for exemption is not one of the ACIP contraindications adopted under 10A NCAC 41A .0404 and printed on DHHS 3987. Listed contraindications are certified on DHHS 3987 and go straight to the school; anything else needs this request and a decision from the State Health Director.
The State Health Director reviews the request, its supporting documentation and the immunization record, and may grant or deny the exemption for the requested vaccines. The physician should keep a copy for the patient's file and give a copy to the person who asked for the exemption.
No. The form states that a physician (MD or DO) licensed to practice medicine in North Carolina must complete and sign it, and it is designed for NC-licensed physicians to request exemptions for contraindications that the NC Commission for Public Health has not adopted.