Since October 1, 2019, North Dakota requires verification of a physical examination dated within 12 months of the application before an initial family foster care license is approved. This one-page form lets the examining office confirm the exam, address prescribed medications and give a professional determination of the applicant's capability to care for children.
A medical professional from the office or clinic that performed the exam completes everything below the applicant and licensing-agent lines and signs with the facility name. The applicant's name and authorized licensing agent are entered at the top.
Download the current version from the source each time; forms change without notice.
Physical Exam Verification Family Foster Homes
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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The physical examination must be dated within 12 months of the date of application to provide foster care. The form asks the medical professional to confirm the exam was completed in the past 12 months in their office or clinic and to give the exam date.
Based on the exam and professional opinion, the clinician checks one: the applicant is capable to provide care to children, is not currently capable, or is capable with supports. When supports are recommended, they are identified in the comments, which also cover strengths or limitations.
The form asks for a medical professional from the office or clinic that performed the exam, with the medical facility name, the professional's printed name, signature and date. It does not limit the signature to physicians, so the clinician who completed the physical can sign.