The 30 Missouri forms clinicians complete, from the WC-9 and Department of Revenue driver forms to MO HealthNet requests, school immunization forms and medical marijuana certifications.
This page lists the Missouri forms clinicians complete, grouped by program, and each group links to its program hub. On workers' comp claims, the treating physician reports treatment, restrictions and any disability rating on WC-9, and eye injuries with permanent disability go on WC-241. The Department of Revenue uses Form 1528, the Physician's Statement, in driver medical reviews, Form 999 for vision and Form 1776 for disabled plates and placards. MO HealthNet drug requests go on Form 2575-017.
Form 1776 must be signed personally by the provider, since stamped or nurse signatures are not accepted, and it is valid for 90 days. On Form 999, the driver signs in front of the examining physician. Medical marijuana certifications by an MD, DO or NP are filed in the DHSS registry portal. PSRS and PEERS disability claims need a statement from each treating physician. The immunization exemption and in-progress forms come in Spanish. Vero Documents fills PDF forms from the visit note and the chart.
Treating physician's report of treatment, surgery, referrals, return-to-work status and restrictions, and any disability rating, with a brief narrative at the final report.
Required physician report for any eye injury resulting in permanent disability, recording acuity, fields and other data to compute the loss of vision.
Attending physician's information on physical rehabilitation received or expected, used by the Division to decide eligibility for physical rehabilitation benefits.
Treating physician's statement on diagnosis, restrictions and permanent incapacity for any occupation for a Public Education Employee Retirement System (non-certificated school staff) disability retirement.
Treating physician documents diagnoses, objective findings, lifting/positional restrictions and whether a Public School Retirement System member is incapable of earning a livelihood in any occupation, permanently, for PSRS disability retirement.
Form 999Eye examination results and opinion on whether the patient's visual abilities are adequate to drive safely.
Form 1528Medical provider's examination findings and opinion on the patient's fitness to operate a motor vehicle, requested by the Driver License Bureau during a driver medical review.
Form 4319Reports firsthand knowledge of a driver believed no longer able to drive safely (cognitive, visual, consciousness, mobility, substance issues), which may trigger medical, vision or driving tests.
Certifies a physical disability under RSMo 301.142.1 for new disabled person license plates or placards (permanent or temporary) and every eighth year at renewal.
Written professional verification of disability required (new and recertifying applicants) for Metro Call-A-Ride ADA paratransit eligibility in St. Louis.
2575-017General MO HealthNet pharmacy prior authorization request for drugs requiring clinical or PDL edits.
Physician certifies a participant's need for MO HealthNet personal care services.
2575-016Physician certificate of medical necessity supporting MO HealthNet coverage of DME and other items/services that require it.
2575-034MO HealthNet fee-for-service prior authorization request for medical services and durable medical equipment.
Physician certification of terminal illness for the MO HealthNet hospice benefit.
Medical examination report required for infants, toddlers and preschool children enrolling in Missouri licensed child care.
Medical examination certifying that a child care provider, staff member or household member is free of communicable disease and able to care for children.
Imm.P.12Medical Immunization Exemption (Spanish)
Signed certification that a student is exempt from one or more Missouri school/child care vaccines because immunization would endanger health or life, or because of documented disease or lab immunity.
Imm.P.14Immunizations in Progress (Spanish)
Lets a child who has begun a required vaccine series attend school or child care by documenting the scheduled next-dose appointment.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
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.
WIC-61Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Certifying physician or nurse practitioner attests that the patient has a qualifying medical condition so DHSS can issue a medical marijuana patient license (also used to certify amounts above 6 oz per month).
Mandated report of suspected child abuse or neglect to the Children's Division hotline unit.
Provider report of a reportable communicable disease or condition (patient, symptoms, diagnostics, treatment, risk factors).
Report of suspected abuse, neglect or exploitation of an elderly person or adult with a disability.
Approved certifier confirms the applicant's vision, hearing, speech, physical or cognitive disability for the state TAP for Telephone, TAP for Internet and TAP Wireless Pilot equipment programs; valid 3 years.
Physician certification that a Missouri resident is legally blind or has a qualifying physical/mental condition (3 CSR 10-5.205) so they may fish without a permit.
Physician certification of a disability (3 CSR 10-20.805(43)): blindness, inability to walk 50 feet, etc., allowing the hunter to hunt from a stationary vehicle or use other exempted methods (e.g. crossbow, laser sight) for a stated duration.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A licensed physician, APRN, physician assistant, chiropractor, podiatrist, optometrist, physical therapist or occupational therapist. The provider must sign personally; stamped signatures and a nurse's signature are not accepted. Form 1776 is needed for new plates or placards, permanent or temporary, and every eighth year at renewal. The statement is valid 90 days, and the applicant submits it with Form 2769.
For any work-related eye injury that results in permanent disability. The treating ophthalmologist, optometrist or physician records acuity, visual fields and the other data used to compute the loss of vision, and sends it to the Division of Workers' Compensation and the insurer. Eye injuries without permanent disability are reported on WC-9, the Medical Treatment Form, like other injuries.
A Missouri-licensed MD, DO or nurse practitioner in good standing first registers a certifier account and is verified by DHSS. The certification is then submitted electronically in the DHSS registry portal, and the patient has 30 days from the signature date to file their application. A patient who needs more than six ounces a month needs one additional certification for the higher amount.
A licensed MD or DO, or their designee, signs Imm.P.12, the Medical Immunization Exemption. It certifies that a vaccine would endanger the child's health or life, or documents disease or lab-confirmed immunity, and it is kept with the school or child care record. A child who has started a series can attend on Imm.P.14, Immunizations in Progress, which lists the next appointment. Both come in Spanish.