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NC DSS-1653 Report of Medical Examination (DMA-5006)

County departments of social services in North Carolina use this report when an applicant's assistance depends on disability. The physician or psychologist documents the complaint, exam findings, diagnosis, restrictions and work capacity in enough detail for a reviewing physician at the state Disability Determination Section to judge severity and duration independently.

Who completes it

A physician or psychologist completes Part III, the medical report. The county DSS fills in Part I (case and patient identification), and the applicant, recipient, personal representative or guardian signs the Part II release to DSS and the Disability Determination Section.

Submitting and payment

How to submit it
Return the completed report, with supporting records, to the county department of social services named at the top of the form. A narrative report may be sent in place of Part III.

Good to know

  • The form asks for copies of office notes, hospital discharge summaries and especially lab, x-ray and other objective study reports covering at least the previous 12 months.
  • Part III includes a cardiovascular block (blood pressure, heart size and sounds, dyspnea and angina by exertion level, American Heart Association functional class, ECG) and a yes/no review of 19 body systems.
  • The report ends with work capacity (full time, part time or none), type and hours restrictions, and an estimate of how long the person will be unable to return to work.
  • The printed edition is DMA-5006 (Rev. 10/91), still carrying the old Department of Human Resources letterhead; DSS-8655 is the separate county work-services medical report.

Get the official form

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

Report of Medical Examination Requested by County Department of Social Services

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

Can I send a narrative report instead of filling out DSS-1653?

Yes. The note to physicians and psychologists in Part III says the form is provided for convenience and that a narrative report is acceptable. Either way, the reviewing physician needs enough detail to judge severity and duration, plus copies of office notes and objective studies from at least the past 12 months.

Who reviews the DSS-1653 after I return it?

The county DSS and the state Disability Determination Section. The applicant's signed release in Part II authorizes providers to share health information with both, and the Part III instructions say a reviewing physician will make an independent determination of the severity and duration of the impairments.

Is DSS-1653 the same form as DMA-5006?

It is one document with two numbers. The PDF is printed 'DMA-5006 (Rev. 10/91)' with 'DSS-1653' beneath it, and it is listed in the NC DHHS policy library as DSS-1653, Report of Medical Examination.