{"id":27512,"date":"2021-04-06T14:38:16","date_gmt":"2021-04-06T18:38:16","guid":{"rendered":"https:\/\/www.med.unc.edu\/pediatrics\/?page_id=27512"},"modified":"2023-08-04T17:50:03","modified_gmt":"2023-08-04T21:50:03","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/pediatrics\/cmep\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<h2>Child Medical Evaluation (CME)<\/h2>\n<ul>\n<li><a href=\"https:\/\/policies.ncdhhs.gov\/divisional\/social-services\/forms\/dss-5143-consent-authorization-for-medical-mental-health-evaluation\" target=\"_blank\" rel=\"noopener noreferrer\">DSS Form 5143 &#8211; Consent\/Authorization Form<\/a> \u00a6\u00a0<a href=\"https:\/\/policies.ncdhhs.gov\/divisional\/social-services\/forms\/spanish\/dss-5143sp-consentimiento-autorizacion-para-evaluacion-de-la-salud-medica-mental-programa-de-evaluacion-medica-del\" target=\"_blank\" rel=\"noopener noreferrer\">Spanish Version of DSS Form 5143<\/a> \u00a6 <a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2021\/04\/DSS-5143-CMEP-Instructions.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Instructions for DSS Form 5143<\/a><\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2022\/09\/Child-Medical-Evaluation-Report-Form.docx\" target=\"_blank\" rel=\"noopener\">CME Medical Report Form<\/a><\/li>\n<li>CMEP Report Guidebook is located on the CMEP Provider Portal<\/li>\n<li><a href=\"https:\/\/policies.ncdhhs.gov\/divisional\/health-benefits-nc-medicaid\/forms\/dma-1061-checklist-for-child-medical-evaluation-cme-reporting\" target=\"_blank\" rel=\"noopener noreferrer\">Checklist for CME Reporting (DMA-1061)<\/a><\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2021\/04\/Form_2488_Case_Conf_Rpt.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Case Conference Report Form<\/a><\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2021\/06\/CMEP-Stakeholder-Meeting-Report-Form-Changes.pptx\">PowerPoint for CMEP FY22: Required Report Form Changes<\/a><\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2021\/04\/dcdee-consent-form-2.pdf\" target=\"_blank\" rel=\"noopener\">DCDEE Consent\/Authorization Form for Child Medical Evaluation<\/a><\/li>\n<\/ul>\n<h2>Clinical Assessment of Protective Parenting (CAPP)<\/h2>\n<ul>\n<li><a href=\"https:\/\/www.med.unc.edu\/pediatrics\/wp-content\/uploads\/sites\/1115\/2023\/08\/CAPP-Authorization-Request-.docx\" target=\"_blank\" rel=\"noopener\">CAPP Authorization Request<\/a><\/li>\n<li><a href=\"https:\/\/policies.ncdhhs.gov\/divisional\/social-services\/forms\/dss-5401-consent-form-for-a-clinical-assessment-of-protective-parenting-capp\/@@display-file\/form_file\/DSS-5401.pdf\" target=\"_blank\" rel=\"noopener\">Consent\/Authorization Form for a Clinical Assessment of Protective Parenting (DSS-5401)<\/a><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Child Medical Evaluation (CME) DSS Form 5143 &#8211; Consent\/Authorization Form \u00a6\u00a0Spanish Version of DSS Form 5143 \u00a6 Instructions for DSS Form 5143 CME Medical Report Form CMEP Report Guidebook is located on the CMEP Provider Portal Checklist for CME Reporting (DMA-1061) Case Conference Report Form PowerPoint for CMEP FY22: Required Report Form Changes DCDEE Consent\/Authorization &hellip; <a href=\"https:\/\/www.med.unc.edu\/pediatrics\/cmep\/forms\/\" aria-label=\"Read more about Forms\">Read more<\/a><\/p>\n","protected":false},"author":3206,"featured_media":0,"parent":27506,"menu_order":3,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"layout":"","cellInformation":"","apiCallInformation":"","footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-27512","page","type-page","status-publish","hentry","odd"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.9 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Forms | Department of Pediatrics<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.med.unc.edu\/pediatrics\/cmep\/forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Forms | Department of Pediatrics\" \/>\n<meta property=\"og:description\" content=\"Child Medical Evaluation (CME) DSS Form 5143 &#8211; 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