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NC Form 703: DIPNC Medical Report for Eligibility

North Carolina members of the Teachers' and State Employees' Retirement System receiving short-term disability under the Disability Income Plan of North Carolina file this form monthly. It combines the member's report of the previous month's earnings with a medical professional's certification that the member has been continuously disabled and unable to perform their regular job, and it goes to the employer, which administers and pays short-term benefits.

Who completes it

The member completes Sections A through D, including the medical release. A certified medical professional, such as a physician, physician assistant, family nurse practitioner, psychiatrist, psychologist or chiropractor, completes Sections E through G, and the employer completes Section H.

Submitting and payment

How to submit it
The member gives the completed form to the employer by the first business day of each month. The medical professional completes it at the time of disability and every 30 days after that.
Who pays
The medical information is furnished at no cost to the employer or the Retirement Systems, and the form says not to send a bill to the retirement system.

Good to know

  • Once the member is approved for preliminary long-term benefits, the medical sections are no longer needed and the member stops after question 3.
  • Diagnoses need full names, each marked as causing or contributing to the disability; the diagnosis code is optional on this form.
  • The Section G certification covers continuous disability from the onset date through the evaluation date or the last day of illness. Stamped signatures are not accepted.
  • No erasures, strikeovers or whiteouts are allowed. Form 7A, the Medical Report for Disability Eligibility Review, is the separate physician form used for the disability application itself.

Get the official form

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

Reporting Earnings and Medical Report for Eligibility Review

Official pagePDF

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

How often does NC Form 703 need a medical professional's signature?

At the time of disability and every 30 days thereafter while the member receives short-term benefits and has not been approved for preliminary long-term benefits. The member submits the form to the employer on the first business day of each month.

Who can complete the medical sections of NC Form 703?

A certified medical professional: a physician, physician assistant, family nurse practitioner, psychiatrist, psychologist or chiropractor completes Sections E through G. Form 7A, by contrast, accepts only a licensed physician's signature.

Can the practice bill for completing Form 703?

The form tells medical professionals not to send a bill to the retirement system, which assumes no responsibility for fees, and the member's release states the information is furnished at no cost to the employer or to the NC Retirement Systems.