Each health visit for a child in Tennessee DCS custody, from a comprehensive exam or well-child check to medical or dental treatment, therapy or lab work, is reported on this form. The provider records the service, vitals, reason for visit, instructions for the caregiver, any referable conditions and follow-up appointments so DCS can track the child's care.
The child's health care provider (medical, dental or behavioral) completes and signs the form with clinic name and address. The child's name, DOB, ERS ID number and home county identify the case.
Download the current version from the source each time; forms change without notice.
Medical Report
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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Comprehensive medical exams and well-child check-ups, medical treatment, dental exams and treatment, therapy or counseling, tests and lab work, and other services described on the form. Psychotropic medication visits are the exception and go on CS-0629.
Page 2 states the completed form is forwarded to the appropriate DCS Health Unit within 5 business days. The units are listed by region and county, each with its own child health email box.
Yes. DCS posts a Spanish version, CS-4286-SP, titled Informe Medico, alongside the English CS-4286 (Rev. 7/25). Both collect the type of service, vitals, the reason for the visit, caregiver instructions, referable conditions and follow-up appointments, followed by the provider's signature.