Try for free

NC DSS-5206 Health Summary: Initial Visit, Foster Care

When a child enters DSS custody in North Carolina, the first medical appointment should happen within 7 days of placement, and the provider records it on this two-page summary. It captures current conditions, medications, immunizations given, allergies, referrals, communicable disease risk and the treatment plan, and schedules the 30-day comprehensive visit.

Who completes it

The child's medical provider completes and signs the form (with a stamp for the provider name). The caregiver who brings the child receives a copy, and the date and person handing it over are recorded at the top.

Submitting and payment

How to submit it
Give a copy to the caregiver at the visit, then send the form and requested attachments to DSS and the CCNC/CC4C care manager; the last box records the date sent and initials.

Good to know

  • Attach the visit summary with vitals, growth parameters, exam findings and the immunization record if available; anything in the attachments does not need to be repeated on the form.
  • The form asks whether the child shows signs of a communicable disease such as hepatitis, TB or lice that could spread in a household, answered yes, no or unknown.
  • There is a yes/no box to request a psychotropic medication review, and a space for instructions to DSS, caregivers and school personnel.
  • It is adapted from the AAP Healthy Foster Care America Health Summary Form; DSS-5208 covers the 30-day comprehensive visit and DSS-5209 covers later well visits.

Get the official form

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

Health Summary Form - Initial Visit (Initial Visit for Infants/Children/Youth in DSS Custody)

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When must the DSS-5206 initial visit happen?

The instructions say providers complete the form at the medical appointment within 7 days of the child's placement. The form then records the date and time of the 30-day comprehensive visit, which is documented separately on DSS-5208.

Can I attach my visit note instead of filling in every field?

Yes. The form asks you to attach the visit summary with vitals, growth parameters and exam findings, plus the immunization record if available, and states you do not have to duplicate information already in the attachments. The remaining fields cover conditions, medications, referrals and follow-up.

Who gets a copy of DSS-5206?

The caregiver gets a copy at the visit, with the date and the name of the person who gave it recorded at the top. The form and requested attachments are also sent to the county DSS and the CCNC/CC4C care manager, and the office notes the date and initials.