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NC DSS-8655 Medical Exam Report for Work First

County social and human services agencies in North Carolina use this two-page report to plan employment services, skills training or other help for clients with health limits, for example in Work First. The physician states whether a condition causes functional limitations for work or training, then details capacity, restrictions, duration and suitability for Vocational Rehabilitation.

Who completes it

A physician completes Part III, which the form says is entirely for the physician, including name, address, specialty and signature. The county agency completes Part I and the client or their representative signs the Part II authorization, valid for up to one year.

Submitting and payment

How to submit it
Return the report to the county agency case manager named in Part I. If there are no functional limitations, answer 'No' to question A and sign and date page 2.

Good to know

  • If limitations exist, the form asks for hours per day the person can attend training, sit, stand, bend, lift, carry and walk, and whether they can understand and follow instructions.
  • Duration is marked as 30, 60, 90, or 120 days or more, permanent, or other, and current work capacity as full time or part time with days per week.
  • Question G asks whether the patient is a candidate for Vocational Rehabilitation; the county agency, not the physician, makes the referral.
  • Restrictions should account for prescribed medications as well as the condition, covering work, driving and training activities.

Get the official form

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

Report of Medical Examination Requested by County Social/Human Services Agency

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.

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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

Do I have to complete both pages of DSS-8655?

Only if the person has a medical or psychological condition causing functional limitations for work or training. If the answer to question A is no, the form tells you to sign and date page 2. If yes, complete both pages, including diagnosis, onset date, capacity and restrictions.

How is DSS-8655 different from DSS-1653?

DSS-8655 asks about functional limits for employment services and training, with hours per activity and a Vocational Rehabilitation question. DSS-1653 is the older full medical examination report used for disability determinations, reviewed by the state Disability Determination Section.

How long is the patient's DSS-8655 authorization valid?

The Part II consent states that it is voluntary and remains valid for up to one year. The client can cancel it at any time by contacting the agency, but cancellation does not affect information already shared.