Get Nc Dss-8655 2018-2025

The NC DSS-8655 form is essential for individuals requesting medical examinations through county social or human services agencies. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully fill out the NC DSS-8655 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Part I, which is designated for completion by the county agency. Provide the patient’s full name, date of birth, social security number (only the last four digits), and address. Ensure all information is up to date and accurate.
3. In Part II, identify the applicant, recipient, personal representative, or guardian. Print their name and the patient's name clearly. This section authorizes medical information sharing with the county social or human services agency.
4. Include the required signature, the relationship to the patient, and the date of signing in Part II. This ensures the consent is legally recognized.
5. Proceed to Part III, which must be completed by the physician. The physician will answer questions regarding the patient's medical or psychological conditions and their impact on work or training.
6. The physician should provide the date and purpose of the most recent medical examination, the diagnosis, and the date of onset in the designated areas.
7. Indicate the patient’s current work capacity by selecting either full-time or part-time, including the number of days worked per week if applicable.
8. In this section, the physician must elaborate on any existing work, driving, or training restrictions related to the patient's medical condition. Include specific details to ensure comprehensive understanding.
9. Answer the question regarding the estimated duration of the individual's condition limiting their work capabilities. Choose the appropriate time frame or specify if it’s permanent.
10. The physician should assess whether the patient is a candidate for Vocational Rehabilitation and include additional comments about work capacity or functional limitations if necessary.
11. Finally, record the physician's name, address, specialty, and provide their signature along with the date. Include contact information such as telephone, fax, and email where indicated.
12. Once all fields are accurately filled, users can save changes, download, print, or share the completed form.

Complete your documents efficiently by filling out the NC DSS-8655 online today.