Workers' comp, SCDMV vision and placard, Medicaid, school, WIC, POST and disease reporting forms from South Carolina agencies, with who completes each one.
South Carolina's clinician forms come from the Workers' Compensation Commission, SCDMV, SCDHHS (Healthy Connections Medicaid), the Department of Public Health (DPH), which took over DHEC's health functions in 2024, and the SCHSL. The forms practices see most are the WCC Form 14B Physician's Statement, the SCDMV 412-NC vision certificate, the RG-007A disability placard application, the D-4024 Certificate of Immunization and the Medicaid universal medication prior authorization request. This hub lists 16 forms, grouped by program.
A few details save return trips. SCDMV vision certificates (412-NC and 412-CDL) are valid 36 months, and the 412-LV low-vision form 12 months. The D-4024 is usually printed from SIMON, the state immunization registry, and doubles as the medical exemption. The Medicaid prior authorization form lists a fax number for fee-for-service and each managed care plan. The POST form is valid as a copy, fax or electronic version. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
WCC Form 14BTreating or evaluating physician's statement of diagnosis, MMI date, permanent impairment ratings, permanent limitations, retained hardware and future medical care needs, used in settlement and hearings.
Physician's statement supporting a South Carolina public employee's claim under the Basic (self-funded) or Supplemental LTD plan.
Eye care professional records acuity and fields for a non-commercial permit or license applicant who did not meet SCDMV vision standards at the counter.
Eye care professional records acuity and fields for a CDL or commercial learner's permit applicant who failed the SCDMV vision screening.
Optometrist or ophthalmologist certifies that a low-vision applicant using bioptic telescopic lenses meets SC Code 56-1-222 standards (initial or annual evaluation).
Physician certifies up to three medical conditions (and a medical provider certifies blood type) so a caduceus symbol can be printed on a non-commercial SC permit, license or ID (SC Code 56-1-80).
Pulmonary physician certifies a medical condition that prevents a driver from operating an ignition interlock device.
Physician's statement certifies a permanent (4-year placard, plates) or temporary (4 months to 1 year) disability, including the autistic/neurodivergent plate option.
Universal pharmacy prior authorization request for South Carolina Medicaid members, with fax numbers for fee-for-service and each managed care plan.
Screens nursing facility applicants for serious mental illness or intellectual/related disability before admission, including attending-physician certification for exempted hospital discharges.
Preparticipation history, physical examination and medical eligibility required for SCHSL athletics.
The single DPH form that certifies a child's required immunizations for child care and K-12 and also serves as the certificate of medical exemption (SC Regulation 61-8).
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
D-4113Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Portable medical order for CPR, scope of treatment and artificial nutrition for patients with serious illness under S.C. Code Title 44 Chapter 80.
Report of a reportable disease or condition (including HIV/AIDS and STDs) by the attending physician or laboratory to public health.
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.
Diagnosis, the MMI date, permanent impairment ratings, permanent limitations, retained hardware and future medical care needs. Settlements and hearings rely on it, so opinions are stated to a reasonable degree of medical certainty; writing that future care may be necessary is not enough. The treating or evaluating physician returns it to the requesting party, usually the carrier or the claimant's attorney, and it is filed with the Commission.
36 months from the exam. A licensed eye care professional completes it when a non-commercial permit or license applicant did not meet SCDMV vision standards at the counter. CDL applicants use the 412-CDL, also valid 36 months. Drivers using bioptic telescopic lenses need the 412-LV from an optometrist or ophthalmologist, valid 12 months. The applicant brings the form to an SCDMV branch, and it is void if altered or erased.
A licensed physician, an APRN (NP, CNM, CNS or CRNA), a physician assistant, or a physical therapist for temporary placards only. The clinician completes Section C, the Physician's Statement, certifying a permanent disability (four-year placard or plates) or a temporary one (4 months to 1 year). The form also covers the autistic/neurodivergent plate option. The applicant takes it to an SCDMV branch or mails it, and permanent placard holders can renew online.
On the South Carolina Certificate of Immunization (D-4024). DPH uses this one form both to certify a child's required vaccines for child care and K-12 and as the certificate of medical exemption. Only a licensed physician (MD or DO), the physician's representative or the health department may issue it. It is usually printed from SIMON, the state immunization registry, and given to the parent for the school or child care.