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Tennessee HS-0120 Child Care Provider Medical Report

The Tennessee Department of Human Services uses this one-page report when a person seeks approval, licensure or employment as a child care provider. The physician answers whether the person has the agility to keep pace with toddlers and the stamina to stay alert for eight hours or more, and notes any condition, limitation or medication that could affect their work with children.

Who completes it

The provider or applicant completes Section A, including the purpose of the exam and their child care duties, and signs the release to DHS. The physician completes and signs Section B.

Submitting and payment

How to submit it
The completed report is returned to the provider or applicant for the Department of Human Services or the child care agency.
Who pays
The form sets no fee and does not address payment for the physician's examination.

Good to know

  • Section A lists the purpose of the exam (initial employment, re-examination or other) and duties such as caregiver, food preparation, driver or facility maintenance.
  • Section B first asks how long the physician has known the patient or had knowledge of their medical history.
  • The physician specifies any physical, mental or emotional limitation affecting the ability to care for a group of children and any medications that could affect the work role.
  • The current version is HS-0120 (Rev. 01-21), and the form states it may not be altered without prior approval.

Get the official form

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

Child Care Provider Medical Report

Official pagePDF

Fill it with Vero

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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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

What does the Tennessee child care provider medical report ask the physician?

The physician answers yes or no on agility to keep pace with toddlers, stamina for eight hours or more, and any condition requiring activity restriction or affecting temperament and interaction with children, then lists limitations, relevant medications and comments.

Who signs Tennessee form HS-0120?

The provider or applicant signs the authorization in Section A allowing the physician to release information to the Department of Human Services. The physician signs and dates Section B; the form has two physician signature lines.

Can Tennessee form HS-0120 be modified?

No. The form states that forms may not be altered without prior approval, and DHS staff are directed to check for the current version. The version in use is HS-0120, revised January 2021.