The Child Medical Evaluation Program is a state-funded resource for North Carolina’s child welfare agencies when assessing concerns for child maltreatment. The Child Medical Evaluation Clinic at Southern Regional AHEC’s Specialty Medicine Center is part of a state network of qualified providers that assist North Carolina child welfare by providing medical evaluations and treatment plans. Below are the forms required to process a referral.

DSS 5143 CMEP Instructions: This document provides step by step instructions for filling out 5143 form

Consent authorization form 5143: This fillable form is designed to assist county child welfare staff in acquiring additional diagnostic services needed to complete a thorough CPS assessment.

Consent authorization form 5143 in Spanish: This fillable form is designed to assist county child welfare staff in acquiring additional diagnostic services needed to complete a thorough CPS assessment.

Past Medical Form: This fillable form provides a checklist and description boxes for the CMEP provider to document findings of CMEP

Past Medical Form in Spanish: This fillable form provides a checklist and description boxes for the CMEP provider to document findings of CMEP

New CME Packet: This fillable form provides information and documentation from referring agency for CMEP referral

To learn more about medical consultations that CMEP provides at the request of child welfare – Child Medical Evaluations. Please contact us at (910) 678-0123 or at CMEP@sr-ahec.org

You can also learn more about the program by viewing the following video, hosted by the NC Department of Health and Human Services: Child Medical Evaluations in North Carolina.