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NC DSS-5209 Health Summary: Well-Visit, Foster Care

Every well visit for a child in North Carolina DSS custody gets a provider summary on this two-page form, or a visit summary containing the same information. It records vision, hearing, developmental and social-emotional screening results, current conditions, medications, immunizations, referrals and the treatment plan, and keeps the county DSS case record current between placements and caregivers.

Who completes it

The child's medical provider completes the form at each well visit and signs it with a name stamp. Staff record who handed a copy to the caregiver and when; the caregiver does not fill in clinical sections.

Submitting and payment

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

Good to know

  • Developmental screening is marked by tool (ASQ, PEDS, MCHAT, PSC or Bright Futures Supplemental-Adolescent) as no concerns or at risk.
  • A specific social-emotional screen is also recorded, with examples such as ASQ-SE, ECSA, PHQ-9, Vanderbilt and SCARED.
  • Vision is recorded as pass or fail, with or without glasses and any referral; hearing as pass or fail. Physical exam details come from the attached visit summary.
  • The form ends with the next well-visit date, a yes/no request for psychotropic medication review and comments for DSS, caregivers and school personnel.

Get the official form

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

Health Summary Form - Well-Visit

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.

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Frequently asked questions

Is DSS-5209 required at every well visit?

Yes. The instructions say the provider completes the form at each well visit for a child in DSS custody, or provides a summary containing the requested information. The initial visit after placement uses DSS-5206 and the 30-day comprehensive visit uses DSS-5208.

Which screenings does DSS-5209 ask for?

Vision (pass or fail, glasses, referral), hearing (pass or fail), a developmental screen such as ASQ, PEDS or MCHAT, and a social-emotional screen such as ASQ-SE, PHQ-9 or Vanderbilt, each marked no concerns or at risk. Vitals, growth and exam findings come from the attached visit summary.

Where does the completed DSS-5209 go?

A copy goes to the caregiver at the visit. The form and visit summary are then sent to the county DSS and the CCNC/CC4C care manager, and the practice records the date and initials in the box at the end of page two.