Dss 8655 of-2026

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The document is a medical examination report requested by the County Department of Social Services to assess an individual's health status and functional limitations for work or training. It includes sections for personal information, authorization for medical information release, and detailed medical evaluations by a physician regarding the individual's conditions, work capacity, and potential referrals to vocational rehabilitation.

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Click ‘Get Form’ to open the dss 8655 in the editor.
Begin with Part I, filling in the Dist. No., Case No., DOB, Patient Name, SSN, Address, Date, and Case Manager's contact information.
In Part II, authorize the release of your medical information by signing and dating the section as the Applicant, Recipient, Personal Representative, or Guardian.
Proceed to Part III for the Medical Report. The physician will need to indicate if there are any medical or psychological conditions affecting work capacity by selecting YES or NO.
If YES is selected, complete sections A through H with detailed information about diagnosis, prognosis, current medications, work capacity restrictions, and vocational rehabilitation eligibility.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (133 Votes)
2005	4.3 Satisfied (117 Votes)

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What is form 8655 used for?

Form 8655 can be used to authorize Reporting Agents to file certain tax returns on paper for existing clients who have already authorized the filing of magnetic/electronic Forms 941 and/or Forms 940 by the Reporting Agent.

What does the NC Department of Health and Human Services do?

The North Carolina Department of Health and Human Services manages the delivery of health and human-related services for all North Carolinians, especially our most vulnerable people children, elderly, disabled and low-income families.

What is the purpose of Form 8655?

Use this form to authorize a reporting agent to: Sign and file certain returns; Make deposits and payments for certain returns; Receive duplicate copies of tax information, notices, and other written and/or electronic communication regarding any authority granted; and.

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How long are 8655 forms good for?

Once Form 8655 is signed, any authority granted is effective beginning with the period indicated on lines 15, 16, 18a, 18b, and/or 18c and continues indefinitely unless terminated or revoked by the taxpayer or reporting agent.

Can form 8655 be signed electronically?

The Reporting Agent may secure and record an electronic signature by capturing the signature of a taxpayer or authorized representative for the purpose of signing Form 8655 on an electronic stylus device in a Point of Sale (POS) environment (only).

How to check the status of form 8655?

Call the IRS at (801) 620-3852 to check the status of Form 8655 applications and for any other questions regarding the Reporting Agent application process. In approximately two weeks, reporting agents receive a mailed notification of accep- tance from the IRS and, in a separate mailing, a five-digit signature PIN.

Dss 8655 of-2026

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