County DSS offices in North Carolina send this one-page report to verify a Food and Nutrition Services (FNS, formerly Food Stamps) client's pregnancy, participation in a drug or alcohol treatment program, or a medical condition limiting work to fewer than 20 hours a week. The answers help the county decide eligibility and work-requirement exemptions.
Any medical personnel may answer and sign, including a physician, physician assistant, nurse, nurse practitioner or a designated representative at a physician's office, listing their profession or position. For the treatment-program question, any representative of the organization running the program may sign; the client signs the authorization.
Download the current version from the source each time; forms change without notice.
North Carolina Food and Nutrition Services Department of Social Services (DSS) Medical Report
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.
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.
Any appropriate medical personnel, including a physician, physician assistant, nurse, nurse practitioner or a designated representative at a physician's office, with their profession or position listed. To verify participation in a rehabilitation program, any representative of the organization operating the program may sign.
No. It asks whether the client is pregnant, whether they are in a drug or alcohol treatment program, which type of condition limits work to under 20 hours a week (mental or physical, or substance dependence) and how long the limitation will last. No diagnosis field appears on the form.
Yes. The form says either the provider or the patient/client should return it to the county DSS by the due date written on it. The client also signs an authorization on the form allowing any physician, hospital or clinic that has treated or examined them to give DSS information about their health.