Physician'S Request For Medical Exemption - Nc Immunization Branch Page 2

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INSTRUCTIONS
1. Complete and sign the form.
2. Provide documentation to support the request (clinic notes, labs, etc).
Attach a copy of the most current immunization record.
3.
4. Retain a copy for the patient’s file.
5. Provide a copy to the person requesting the medical exemption.
6. Send the completed form, supporting documentation and the current immunization record to:
State Health Director
Department of Health and Human Services
Immunization Branch
1917 Mail Service Center
Raleigh, NC 27699-1917
For questions call (919)707-5550.
Additional copies of this form can be accessed at:
DHHS 3995 (Revised 6/15)
Immunization (Review 6/17)

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