The 11 Mississippi forms clinicians complete, from disabled parking and driver medical forms to TANF exam reports, vaccine medical exemptions and medical cannabis certifications.
This page lists the Mississippi forms clinicians complete, grouped by program, and each group links to its program hub. The one most offices see is Form 76-104, the Mississippi Disabled Parking Application, which a licensed physician or nurse practitioner certifies. The Department of Public Safety uses DR-11, its medical form for drivers under review, and DE-26 for vision specialists. Schools ask for the MHSAA Athletic Pre-Participation Form, and a vaccine medical exemption starts with Form 139-M.
The clinician, not the driver, sends DR-11 and DE-26 to the Driver Records Medical Division, and each is valid for one year. Form 139-M goes to the State Epidemiologist, and only the Form 122 certificate that MSDH issues proves the exemption. MDHS reimburses the physician for the MDHS-EA-331 Report of Medical Examination used in TANF work exemptions. Medical cannabis certifications are submitted in the MSDH licensing portal. Vero Documents fills PDF forms from the visit note and the chart; the clinician reviews and signs.
Ophthalmologist's or optometrist's report of acuity with and without lenses and field of vision for a driver under medical/vision review.
Physician's medical report used by DPS to decide on licensing after a safety concern letter or examiner referral (seizures, physical impairment, etc.), before a driving evaluation.
Applies for a permanent or temporary (up to 6 months) disabled parking placard or disabled license tag, with certification of a qualifying walking/lung/cardiac condition (Miss. Code 27-19-56).
Physical examination form required for participation in Mississippi high school athletics.
Form 139-MPhysician request for a medical exemption from Mississippi school/child care vaccines, reviewed by the State Epidemiologist, who then issues the Certificate of Medical/Religious Exemption (Form 122).
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Registered practitioner certifies that a patient has a debilitating medical condition so MSDH can issue a medical cannabis identification card.
Report of suspected child abuse or neglect to MDCPS Centralized Intake.
Provider report of a reportable disease or condition, with diagnosis, lab and treatment details.
Report of suspected abuse, neglect or exploitation of a vulnerable person under the Vulnerable Persons Act.
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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A licensed physician or nurse practitioner completes Section 1 of Form 76-104, certifying a qualifying walking, lung or cardiac condition. The form covers a permanent placard, a temporary placard of up to 6 months, or a disabled license tag, and the certifier states the date beyond which the disability should not extend. The applicant takes the form to the county tax collector.
The child's Mississippi-licensed pediatrician, family physician or internist completes Form 139-M, marking each vaccine as a permanent, temporary or no exemption with an expiration and the medical reason. The physician sends it to the State Epidemiologist. If approved, MSDH issues the Certificate of Medical/Religious Exemption, Form 122, and mails a copy to the parent and physician. Only Form 122 is official proof.
Only the licensed medical professional, by email or mail to the DPS Driver Records Medical Division. The driver receives DR-11 with a 30-day Notice of Concern letter after a safety concern or examiner referral, such as seizures or a physical impairment. The professional completes every section after the patient authorization, and the form is valid one year from completion. Vision specialists use DE-26.
An MSDH-registered MD, DO, nurse practitioner, physician assistant or optometrist, and only an MD or DO for minors. Practitioners register each year and complete MSDH-approved continuing education. The first certification needs an in-person visit, and recertification can be by telehealth. The practitioner submits it in the MSDH licensing portal, and it is valid for 1 year unless a shorter period is set.