Workers' comp, Medicaid, DMV, school and child care, MOST and DNR, and involuntary commitment forms from North Carolina agencies, with who completes each one.
North Carolina's forms come from the Industrial Commission, NC Medicaid, the DMV, the Division of Social Services, the Retirement Systems Division and DHHS. Clinicians meet these most: the Medical Orders for Scope of Treatment (MOST), the Health Assessment Transmittal Form for school entry, the DMV Medical Report Form (DL-78), the Personal Care Services attestation (DHB-3051) and the First Examination for Involuntary Commitment (DMH 5-72-19). This page lists all 50 North Carolina forms, grouped by program.
Several forms have print rules: the MOST must go on Pulsar Pink paper and the DNR order on goldenrod, and only physicians' offices and licensed facilities may download them. Return the DL-78 to the DMV Medical Review Unit within 30 days, or the license may be cancelled. Deaths are certified online in NCDAVE. Don't bill the Retirement System for the Form 7A; it will not pay. Spanish versions exist for 8 of these forms, including the school health assessment.
Commission-approved questionnaire the employer/insurer may send to treating providers about diagnosis, causation, work status, restrictions and MMI on an admitted claim.
Requests insurer preauthorization of surgery or inpatient admission, with an appeal page if the initial request is denied.
Physician's rating of permanent partial impairment by body part (including amputation levels) for scheduled-loss compensation.
Employee applies for additional medical compensation after the claim closed; an optional treating physician statement supports the need for further treatment.
Employee asks to reinstate disability compensation after a failed trial return to work, supported by the treating physician's statement that the employee could not continue working.
Licensed physician documents diagnoses (ICD-10), onset, treatment, mental assessment and whether the member is temporarily or permanently unable to perform their job, for disability retirement (TSERS, LGERS, CJRS, LRS, Firefighters' & Rescue Squad Workers' Pension Fund) and DIPNC benefits.
Monthly earnings report plus a medical professional's certification that a TSERS/ORP member is continuously disabled and unable to perform their regular job, for short-term benefits under the Disability Income Plan of North Carolina (DIPNC).
DL-78Multi-section report (general, vision, cardiovascular, endocrine/diabetes, neurological, psychiatric, substance use, etc.) the Medical Review Unit sends to a driver so their physician can document fitness to drive and recommend restrictions.
Licensed medical provider certifies a mobility impairment (G.S. 20-37.5) for a temporary (1-6 months), regular or total-and-permanent disability parking placard.
Health care provider's verification of the applicant's disability and how it affects use of fixed-route buses, for CATS STS ADA paratransit eligibility.
Medical provider certifies a qualifying mobility impairment so the applicant can register a vehicle with disability license plates.
Renews a disability placard; a medical provider recertifies the impairment when recertification is required.
Practitioner refers a beneficiary for a Personal Care Services independent assessment and attests to the medical need for PCS.
NC Medicaid-372-124Physician's level-of-care certification (FL-2) for nursing facility, adult care home and other long-term care placement.
NC Medicaid-372-131Combined certificate of medical necessity and prior approval request for durable medical equipment, orthotics/prosthetics and supplies under NC Medicaid Direct.
Standard pharmacy prior authorization / PDL exception request for NC Medicaid Direct beneficiaries.
Physician's signature page authorizing the level of care (e.g., nursing facility) requested for an NC Medicaid beneficiary through NCTracks.
Audiologist/physician requests NC Medicaid prior approval for hearing aids and related services.
DMA372-017AOptometrist/ophthalmologist requests NC Medicaid prior approval for eyeglasses or other visual aids beyond standard coverage.
NC Medicaid-3075Physician requests and justifies private duty nursing hours for a Medicaid beneficiary.
NC Medicaid-3402Requests EPSDT coverage of a service not covered by the State Plan (or beyond its limits) for a beneficiary under 21.
Formulario de Evaluación de Salud y Transmisión de Carolina del Norte
Transmits the health assessment required within 12 months before a child first enters a North Carolina public school (G.S. 130A-440).
Children's Medical Report (Español)
Physical examination report required for children enrolling in North Carolina licensed child care centers and family child care homes.
Pre-employment statement that a child care center staff member is emotionally and physically fit to care for children (10A NCAC 09 .0701).
TB risk questionnaire and test results required for child care center staff and family child care home operators (10A NCAC 09 .0701, .1702, .1729).
Health care professional's waiver allowing an infant in child care to sleep in an alternative position or use a wedge (10A NCAC 09 .0606(e), .1724(e)).
PPE Part 2; PPE Part 3Annual physical exam and medical eligibility certificate required before a student-athlete participates in NCHSAA sports.
Provider's academic accommodation recommendations for a student recovering from concussion.
Licensed health care provider's evaluation and recommendations for a student-athlete with a suspected concussion under North Carolina's Gfeller-Waller Concussion Awareness Act.
Documents the graduated return-to-play progression and the licensed provider's final written clearance after concussion, required by the Gfeller-Waller Act.
DHHS 3987Lets an NC-licensed physician certify a medical exemption for contraindications adopted by the NC Commission for Public Health (10A NCAC 41A .0404), accepted by schools, child care and colleges without state review.
Physician request to the State Health Director for a medical exemption based on a contraindication not listed on DHHS 3987.
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.
Referral 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.
Physician order sheet for CPR, scope of treatment, antibiotics and nutrition under N.C.G.S. 90-21.17, honored across settings and by EMS.
Electronic death registration system in which North Carolina medical certifiers complete the cause-of-death certification.
Portable out-of-hospital DNR order directing that CPR not be initiated, honored by EMS statewide (N.C.G.S. 90-21.17).
DMH 5-72-19First-level commitment examination finding whether the respondent meets criteria for inpatient, outpatient or substance use involuntary commitment, sent to the clerk of superior court.
DMH 5-72-19-2Second (24-hour facility) examination deciding whether a respondent held on an IVC remains committable, with recommendation to the court.
DMH 5-72-20AEmergency certificate attached to the first examination certifying that the respondent requires immediate hospitalization to prevent harm, with a transport request (emergency procedure without a custody order).
North Carolina physician (or authorized government agency) certifies that an applicant was totally and permanently disabled and under their care on January 1, for the Elderly or Disabled Homestead Exclusion and Circuit Breaker deferral.
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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Physicians' offices and licensed facilities download and print them from the Office of Emergency Medical Services, which no longer mails forms. The MOST must be printed on Astrobrights Pulsar Pink paper. A physician, NP or PA completes the orders in sections A to D with the patient or representative and signs. The form stays with the patient. The out-of-hospital Do Not Resuscitate Order is a separate form, printed on goldenrod paper.
By the child's first day of attendance. G.S. 130A-440 requires a health assessment within the 12 months before a child first enters a North Carolina public school. A physician, PA, NP or local health department completes the provider section with exam findings, screenings, signature and practice information. The parent delivers it to the principal. It comes in English and Spanish.
A physician, an eligible psychologist, or a DHHS-certified first-level commitment examiner such as an LCSW, LCMHC, NP or PA. Examiners other than physicians and psychologists must hold the certification. The DMH 5-72-19 records whether the respondent meets criteria for inpatient, outpatient or substance use commitment. Copies go to the clerk of superior court, the 24-hour facility or outpatient provider, and the area facility. For immediate hospitalization, attach the DMH 5-72-20A certificate.
General health, vision, cardiovascular, endocrine and diabetes, neurological, psychiatric and substance use sections, across 10 pages. The DMV Medical Review Unit usually mails it to the driver prefilled with the condition under review. The treating physician completes the condition sections, and a licensed ophthalmologist or optometrist completes the vision section. Return it within 30 days or the license may be cancelled.