Consent/Authorization Form for Child Medical & Child/Family Evaluations
DSS-5143 (Rev. 10/2020)
Child Welfare Services
Page 1 of 2
Name of Child Date of Birth
Name of Child Date of Birth
Name of Child Date of Birth
I hereby authorize to perform:
A Child Medical Evaluations (CME), including diagnostic studies and photographs, on the above-named child.
A Child/Family Evaluation (CFE), including diagnostic studies, on the above-named child.
Furthermore, I authorize the above-named examiner to release the entirety of the medical record to (All items must
be checked):
A county department of social services (DSS) providing protective services to the above-named child
NC Child Medical Evaluation Program (CMEP)
NC Division of Social Services
I understand that, as the parent/legal guardian, I will not have access to Child Medical Evaluation or Child &
Family Evaluation reports.
I understand that limited information can be shared with the parent/legal guardian and medical and/or mental
health professionals providing care to the child post-evaluation. This may include:
Mental health symptoms
Physical exam findings
Laboratory studies
I acknowledge that this evaluation is used to make determinations of child maltreatment and is a component of
a NC child protective services assessment.
This referral is made by authority of (check one):
Parent
Legal Guardian
DSS Director - When acting as temporary guardian of a child found abandoned or without a natural guardian
(G.S. § 35A-1220) or when having been vested with parental rights by the adoption or termination of
parental rights laws (G.S. §§ 48-3-705 and 7B-1112).
Judge’s Order - In accordance with G.S. § 7B-505.1, when a court order authorizes this evaluation.
_________________________________________________________Date:_
Signature of parent/guardian
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Consent/Authorization Form for Child Medical & Child/Family Evaluations
DSS-5143 (Rev. 10/2020)
Child Welfare Services
Page 2 of 2
(To be completed by the referring county DSS)
The provider listed above is authorized to claim reimbursement in accordance with the Purchase of Service Contract
for the services, if child is the subject of an open CPS Assessment and a county child welfare agency has referred the
child for a CME/CFE.
Case open for CPS Assessment (Service Code 210 and 212): YES NO
County: SIS or CNDS#:
Is Medicaid the primary insurer: YES NO Medicaid#
I authorize the referral for the above-named child(ren) to receive a CME/CFE at the request of
County DSS.
Date:
Signature of county DSS representative
County Child Welfare worker: Phone:
Email:
County Child Welfare supervisor: Phone:
Email:
Select County
Select County
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