Physician'S Request For Medical Exemption - Nc Immunization Branch printable pdf download

North Carolina Department of Health and Human Services

Women’s and Children’s Health Section ▪ Immunization Branch

PHYSICIAN’S REQUEST FOR MEDICAL EXEMPTION

Purpose: To provide physicians, licensed to practice medicine in North Carolina, with a mechanism to request a medical

exemption from the State Health Director that is not specified in the North Carolina Administrative Code (10 NCAC 41A.

0404) and not listed on the Medical Exemption Statement form (Form: DHHS 3987), available at

Name of Patient ___________________________________________________DOB______________________________

Name of Parent/Guardian ______________________________________Primary Phone (

) ______________________

Home Address (Patient/Parent) ______________________________________________County____________________

Name of Child Care/School/College/University____________________________________________________________

G.S. 130A-156. Medical exemption. The Commission for Health Services shall adopt by rule a list of medical contraindications to immunizations

required by G.S. 130A-152. If a physician licensed to practice medicine in this State certifies that a required immunization is or may be detrimental

to a person’s health due to the presence of one of the contraindications listed by the Commission, the person is not required to receive the

specified immunization as long as the contraindication persists. The State Health Director may, upon request by a physician licensed to practice

medicine in this State, grant a medical exemption to a required immunization for a contraindication not on the list adopted by the Commission.

Please mark the vaccine(s) that the proposed medical exemption(s) apply to:

DTaP

MMR

Hepatitis B

Tdap

Varicella

Hib

DT/Td

IPV

Meningococcal

Pneumococcal Conjugate

Other (Specify)______

For each vaccine marked above, please describe the contraindication(s) and the proposed length of time that would

apply: ____________________________________________________________________________________________

________________________________________________________________________________________________________________________

A physician (M.D. or D.O.) licensed to practice medicine in NC must complete and sign this form.

N.C. Physician’s Name (please print)

Phone __________________________

_____________________________________________

Address

________________________________________________________________________________________________________________

N.C. Physician’s Signature

Date

_______________________________________________________

_________________________________

DHHS 3995 (Revised 6/15)

Immunization (Review 6/17)

Physician'S Request For Medical Exemption - Nc Immunization Branch