Tennessee DCS asks for this one-page verification to support continued adoption assistance for a child's medical or mental health needs. The licensed professional currently treating the child confirms the date of the most recent visit or appointment and signs with credentials and agency details, under a statutory warning against false statements.
The licensed treating professional providing services to the child completes Sections 2 and 3: the date of the most recent visit, printed name and credentials, signature, date, phone number and agency or organization. Section 1, the child's identifying information, must have every field completed.
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Verification of Medical/Mental Health Provider Visit (for Adoption Assistance)
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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The licensed treating professional who is providing medical or mental health services to the child. Section 3 asks for the provider's printed name and credentials, signature, date, phone number and agency or organization name.
No. The form asks only for the date of the most recent visit or appointment, plus the licensed provider's information and signature. It does not ask for a diagnosis, treatment details or attached records.
The form quotes Tennessee Code 36-1-205: anyone who knowingly obtains, or helps someone obtain, assistance under the Interstate Compact on Adoption and Medical Assistance through a willfully false statement, impersonation or other fraud commits a Class E felony.