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NC DSS-5215 Verification of Child's Health Condition

North Carolina's Special Children Adoption Incentive Fund relies on this one-page physician certification. The physician names the child, describes the health condition and the resulting impairment, and certifies that the condition is expected to significantly impair the child's ability to function at home, at school or in the community throughout childhood.

Who completes it

A physician completes the certification, writes in the condition and impairment, and signs and dates it. The county name at the top and the child's name identify the case; no other party signs the form.

Submitting and payment

How to submit it
Return the signed certification to the county DSS adoption worker who requested it, for the child's adoption assistance file.

Good to know

  • The certification has two parts that both need support: significant impairment in functioning at home, school or community, and an expectation that it will last throughout childhood.
  • There is a single open space for the condition and impairment, so a short statement naming the diagnosis and its functional effect fits the format best.
  • The form is printed 'DSS-5215 (Revised August 2003)' under Family Support and Child Welfare Services, and it has no checkboxes or worker section.
  • Only a physician's signature line appears on the form; there is no line for a nurse practitioner, psychologist or other professional.

Get the official form

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

Special Children Adoption Incentive Fund Verification of Child's Health Condition

Official pagePDF

Fill it with Vero

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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

What must a physician certify on DSS-5215?

That the named child has a health condition expected to result in significant impairment in the child's ability to function in the home, school or community, and expected to endure throughout childhood. The physician then writes in the condition and the resulting impairment before signing and dating.

Who uses the DSS-5215 verification?

County DSS adoption staff in North Carolina, for the Special Children Adoption Incentive Fund. The completed form goes back to the county adoption worker, who files it with the child's adoption assistance case.

Is DSS-5215 a long form?

No. It is one page with a county line, the child's name, the printed certification statement, one space for the condition and resulting impairment, and the physician's signature and date. It is printed 'DSS-5215 (Revised August 2003)'.