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INDIANA HEALTH CARE REPRESENTATIVE APPOINTMENT

Details: The health care provider if the representative knows there is one. 12. An individual who is capable of consenting to health care may revoke: a. The appointment at any time by notifying the representative orally or in writing; or b. The authority granted to the representative by notifying the health care provider orally or in

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APPLICATION FOR ENDORSEMENT AS A HEALTH INDIANA STATE

Details: health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2.

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AUTHORIZATION FOR DISCLOSURE OF PERSONAL AND HEALTH

Details: What personal information, including health information, are we to disclose? Please describe the type of information we are allowed to disclose; for example, your contact information, your benefits status, your medical condition, your healthcare payment status and history, or “as requested by the authorized person/organization.”1

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RENEWAL APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH

Details: INDIANA STATE DEPARTMENT OF HEALTH ATTENTION: CASHIER’S OFFICE 2 NORTH MERIDIAN STREET, SUITE 2-C INDIANAPOLIS, INDIANA 46204 . Title: Microsoft Word - 48851.doc Author: sbundy Created Date:

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AUTHORIZATION FOR DISCLOSURE OF PERSONAL AND HEALTH

Details: What personal information, including health information, are we to disclose? Please describe the type of information we are allowed to disclose; for example, your contact information, your benefits sta-tus, your current eligibility status and/or historical status, or “as requested by the authorized person/organization.” 1

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HEALTH CARE PROGRAM FOR CHILD CARE FAMILY AND SOCIAL

Details: HEALTH CARE PROGRAM FOR CHILD CARE HEALTH RECORD - CHILD State Form 49969 (R5 / 7-19) Name of child (last, first)Address (number and street, city, state, and ZIP code)Child lives with (relationship)Date of birth (month, day, year) Date of admission (month, day, year)Name Telephone number

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APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH AGENCY

Details: Home Health Aide Medical Social Services Nursing Occupational Therapy Physical Therapy Speech Therapy Other (List all) _____ _____ E. Types of personal services to be provided Do you provide services as performed by a personal services agency under IC 16-27-4? Yes No If yes, check

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State Form 54808 (R / 9-13) Approved by State Board of

Details: Please send this request(s) with a check or money order payable to the Indiana State Department of Health, along with a copy of a valid Government, State, or Military identification to: ISDH Vital Records 2 North Meridian Street Indianapolis, IN 46204 Please note: Incomplete information will prevent an adequate search.

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IARA: State Forms Online Catalog

Details: A health care representative who resigns or is unwilling to comply with the written appointment may not exercise further power under the appointment and shall so inform the following: The patient / appointor. The patient’s / appointor’s legal representative if one is known.

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IARA: State Forms Online Catalog

Details: qualified medication aide (qma) record of annual inservice training. state form 51654 (r4 / 1-20) indiana state department of health – division of health care quality & education

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HEALTH CARE PROGRAM FOR CHILD CARE FAMILY AND SOCIAL

Details: HEALTH CARE PROGRAM FOR CHILD CARE RECORD OF ADULT PHYSICAL HEALTH EXAMINATION State Form 49970 (R6 / 7-19) Name Address (number and street, city, state, and ZIP code)Date of birth (month, day, year)I. List past hospitalizations / operations / accidents:

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INDIANA LIVING WILL DECLARATION

Details: Indiana State Department of Health – IC 16-36-4 This declaration is effective on the date of execution and remains in effect until revocation or the death of the declarant. This declaration should be provided to your physician. LIVING WILL DECLARATION Declaration made this day of (month, year). I, ,

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BRANCH QUESTIONNAIRE FOR A HOME HEALTH AGENCY

Details: Branch office means a location or site from which a home health agency provides services within a portion of the total geographic area served by the parent agency. The branch office is part of the home health agency and is located sufficiently close to share administration, supervision, and home health agency. questionnaire.

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APPLICATION FOR APPROVAL TO OPERATE A INDIANA STATE

Details: Indiana State Department of Health – Division of Health Care Education and Quality INDIANA STATE DEPARTMENT OF HEALTH DIVISION OF HEALTH CARE EDUCATION AND QUALITY 2 North Meridian Street, Suite 4-B Indianapolis, IN 46204 INSTRUCTIONS: 1. Please complete the appropriate sections on both sides of the application. All applications must be

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APPLICATION FOR LICENSE TO OPERATE A HEALTH FACILITY

Details: operating, or has operated, health facilities in Indiana or any other state, that: 1. Has/had a record of operation of less than a full license (i.e. three month probationary, provisional, etc) Yes No (If “Yes”, provide name of facility, state, date(s), restrictions and type.) 2. Had a facility’s license revoked, suspended or denied.

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NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH

Details: about how your personal health care information is used and protected, and your health coverage privacy rights. 5. You will need to answer all questions that are required to determine eligibility. 6. Eligibility for benefits is determined without any regard to race, color, creed, sex, age, disability, national origin, or political belief.

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AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE

Details: FOR HEALTH COVERAGE State Form 55366 (R2 / 12-14) / DFR 2123HC Section 1 If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do.

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INDIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (POST)

Details: Indiana State Department of Health – IC 16-36-6 INSTRUCTIONS: This form is a physician’s order for scope of treatment based on the patient’s current medical condition and preferences. The POST should be reviewed whenever the pat ient’s condition changes. A POST form is voluntary. A patient is not required to complete a POST form.

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Resident Information - Indiana

Details: The health of the individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or payment has not been made under Medicare/Medicaid for a stay in a nursing facility. The facility ceases to operate.

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REGISTRATION APPLICATION FOR A TEMPORARY Return completed

Details: Indiana State Department of Health – Food Protection Program Return completed form to: Indiana State Department of Health Food Protection Program, Room N855 100 N. Senate Ave. Indianapolis, IN 46204 317/234-8569 (fax) 317/233-9200 Please complete a form for each separate operation. 410 IAC 7‐24‐107 PREREQUISITE FOR OPERATION

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PATERNITY AFFIDAVIT – HOSPITAL USE

Details: Local Health Department Number File Date (mm/dd/yyyy) State File Number PA Number SECTION E – NOTICE OF CONSEQUENCES, ALTERNATIVES, RIGHTS AND RESPONSIBILITIES By signing this affidavit, I acknowledge that I have read and understand all of the following: 1. A man should NOT sign this form if he is not sure he is the biological father.

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IARA: State Forms Online Catalog

Details: INDIANA STATE DEPARTMENT OF HEALTH. STATE OFFICE USE ONLY. STATE OFFICE USE ONLY. PART I. This information will be used to prepare the new certificate of birth. (Specify) 13. Name of Attorney or Agency handling Case. Mailing Address (number and street, city, state, and ZIP code) PART II. This information must be given as of date of birth.

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Indiana State Department of Health Laboratory RABIES

Details: All rabies specimens must be properly packaged before delivery to the Indiana State Department of Health (ISDH) Laboratories. For high priority specimens, please alert the lab (317.921.5834) and send a fax copy of the LimsNet cover sheet or rabies submission form (317.927.7804). Provide tracking numbers when available.

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APPLICATION FOR SEARCH AND CERTIFIED COPY OF BIRTH RECORD

Details: INDIANA STATE DEPARTMENT OF HEALTH BIRTH RECORDS IN THE STATE VITAL RECORDS OFFICE BEGIN WITH OCTOBER 1907. Prior to October 1907, records of birth are filed ONLY with the local health department in the county where the birth actually occurred. FEES ARE ESTABLISHED BY LAW (IC 16-37-1-11 and IC 16-37-1-11.5). Each search for a record costs $10.00.

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HEALTH CARE PROGRAM FOR CHILD CARE CENTERS PROCEDURE FOR

Details: Signature of health care consultant Date signed (month, day, year) Remove gloves. Put diaper on child. Wash child’s hands. Take child to safe area. If blood is present on diaper table, put medical gloves on. Discard soiled diaper, washcloth and towel, and wax paper into tightly covered sanitary waste container lined with plastic bag.

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IARA: State Forms Online Catalog

Details: Author: Trilogy Health Services Last modified by: sbundy Created Date: 1/20/2003 3:02:45 PM Company: Trilogy Health Services Other titles: Sheet1-Total Page Page 2 Page 3 Sheet4 Sheet5

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Guidance for Completing State Form 9966

Details: Indiana State Department of Health 2 North Meridian Street, Section B4 In d i a n apo li s, In d i a n a 4 6 2 0 4 Mother Father Family Adoptee k. Birth Weight, Length, and APGAR Scores j. Newborn Screening Disorders i. Other h. Complications of Delivery g. Prematurity f. Hypoxia e. Isoimmune d. Alcohol/Drug Exposure c. Neonatal Deaths b

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INDIANA STATE DEPARTMENT OF HEALTH OFFICE OF HIPAA COMPLIANCE

Details: INDIANA STATE DEPARTMENT OF HEALTH OFFICE OF HIPAA COMPLIANCE Purpose: This form is used to document each disclosure of protected health information that we make for which we are obligated to account on an individual’s request. This form is also used to document our compliance with the minimum necessary requirement.

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Instruction for completion: Health Programs

Details: Health and medical records are current, on file in the licensed facility for each child and contain the following information: Yes NoThe prescriber's written instructions regarding any special dietary or other special health care the child may need.

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INDIVIDUALIZED MENTAL HEALTH SAFETY PLAN

Details: INDIVIDUALIZED MENTAL HEALTH SAFETY PLAN State Form 56901 (3-20) FAMILY AND SOCIAL SERVICES ADMINISTRATION DIVISION OF MENTAL HEALTH AND ADDICTION INSTRUCTIONS: 1. Develop the Individualized Mental Health Safety Plan in collaboration with the individual and/or their parent/guardian, legal representative, etc. prior to discharge.

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QUALIFIED MEDICATION AIDE (QMA) RECORD OF ANNUAL INSERVICE

Details: INDIANA STATE DEPARTMENT OF HEALTH – DIVISION OF HEALTH CARE QUALITY & EDUCATION INSTRUCTIONS: 1. Please print or write clearly. 2. Six (6) hours of inservice training must be completed each year (January – December). 3. Only inservices related to medications, medication administration, QMA Scope of Practice, and

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HOME HEALTH AIDE REGISTRY RENEWAL - Indiana

Details: HOME HEALTH AIDE REGISTRY RENEWAL State Form 49561 (R9 / 2-20) INDIANA STATE DEPARTMENT OF HEALTH - DIVISION OF ACUTE AND CONTINUING CARE * This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

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SWIMMING POOL RECORD OF OPERATION - Indiana

Details: INDIANA STATE DEPARTMENT OF HEALTH Pursuant to 410 IAC 6-2.1 and 38, this form must be logged daily and retained for one (1) year. Name of facility Week ending date (month, day, year) Type of pool (indoor, outdoor, wading, wave, spa, waterslide, other pool) Day DAILY WEEKLY Name of Person Logging Entry Disinfectant Residual Cl 2, Br (ppm) pH

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FACILITY COMPLETES COLUMNS A, B, AND C. MAKE ADDITIONAL

Details: employee records state form 5440 (r5 / 3-18) indiana state department of health division of long term care facility label date (month, day, year) facility completes columns a, b, and c. make additional copies as needed.

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INDIANA STATE DEPARTMENT OF HEALTH II. STATE HEALTH

Details: Lake County Health Department Attention: HIV/AIDS Surveillance Project Director 2900 W. 93rd Street Crown Point, Indiana 46307 Reports for Residents of All Remaining Counties should be sent to: Office of Clinical Data and Research Indiana State Department of Health 2 N. Meridian Street, 6‐C

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APPLICATION FOR SEARCH OF CERTIFIED OR NON-CERTIFIED COPY

Details: Mail this application(s) with a check or money order payable to the Indiana State Department of Health, along with a copy of your Government, State, or Military valid identification and/or required documentation to: Indiana State Department of Health, Vital Records Division, 2 North Meridian Street, Indianapolis, IN 46204.

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THIS FORM MUST BE SUBMITTED ALONG WITH THE COURT ORDER FOR

Details: INDIANA STATE DEPARTMENT OF HEALTH Per IC 31-14-9-2, no later than the tenth (10) day of each month, the clerk of courts shall forward this form to: the Indiana State Department of Health Vital Records – COPD, 2 North Meridian Street, Indianapolis, IN 46204. THIS FORM MUST BE SUBMITTED ALONG WITH THE COURT ORDER FOR THE BIRTH RECORD TO BE

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SUPPLEMENTAL HEALTH CARE PROGRAM FOR CHILD CARE FSSA

Details: SUPPLEMENTAL HEALTH CARE PROGRAM FOR CHILD CARE CENTERS PROVIDING INFANT-TODDLER CARE SUGGESTED FEEDING PLAN State Form 49963 (R3 / 2-15) INSTRUCTIONS: Prior to admission, a feeding plan shall be established and written for each infant (age six (6) weeks to twelve (12) months) in consultation with the parents and

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PROVIDER SERVICES ADMINISTRATOR OR DIRECTOR OF NURSING CHANGE

Details: INDIANA STATE DEPARTMENT OF HEALTH DIVISION OF LONG TERM CARE 2 North Meridian Street, Section 4B Indianapolis, IN 46204 Telephone: (317) 233-7794 Fax: (317) 233-7322 E-mail: [email protected] The Indiana State Department of Health must be notified each time that a facility has a change in administrator or director of nursing.

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REPORT OF LATENT TUBERCULOSIS (TB) INFECTION

Details: Health Care Worker (Check if evaluation was done due to positive TST or Interferon Gamma Release Assay (IGRA) through baseline or annual testing.) Employment / Administrative Testing (Check if evaluation was a result of routine employment physical exam,

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APPLICATION FOR LICENSURE AS A BEHAVIORAL HEALTH AND HUMAN

Details: Agency, or Behavioral Health and Human Services Licensing Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives in connection with processing my application for licensure.

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CHILDREN’S SPECIAL HEALTH CARE SERVICES (CSHCS)

Details: CHILDREN’S SPECIAL HEALTH REQUEST FOR AUTHORIZATION State Form 55653 (8-14) INDIANA STATE DEPARTMENT OF HEALTH CARE SERVICES (CSHCS) The CSHCS Prior Authorization (PA) Unit telephone number is (800) 475-1355, or (317) 233-1351, then select the PA option.

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CSHCS ENROLLMENT PACKET THIS PACKAGE CONTAINS CONFIDENTIAL

Details: Health care received in the past twelve (12) months (copy additional pages of this section as needed). List the primary care physician for all well-child care including immunizations and illness. List the dentist (if applicable), clinics and other medical care providers by specialty type.

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within ten (10) days - Indiana

Details: Health within ten (10) days of your receiving the notice of transfer or discharge from the facility to: Indiana State Department of Health Court Administrator, Office of Legal Affairs 2 North Meridian Street – Section 3-H Indianapolis, Indiana 46204

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EMPLOYEE'S AUTHORIZATION FOR RELEASE STATE OF INDIANA OF

Details: I, EMPLOYEE'S AUTHORIZATION FOR RELEASE STATE OF INDIANA OF MEDICAL INFORMATION State Form 50107 (R4 / 7-17) State Personnel Department, Benefits Division Disability Program

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NOTICE OF TRANSFER OR DISCHARGE REQUEST FOR HEARING

Details: Indiana State Department of Health. Court Administrator, Office of Legal Affairs. 2 North Meridian Street – Section 3-H. Indianapolis, Indiana 46204 I received a Notice of Transfer or Discharge from the health facility informing me that I am going to be transferred or discharged from the facility.

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APPLICATION FOR CERTIFICATION AS AN ADDICTION TREATMENT

Details: DIVISION OF MENTAL HEALTH AND ADDICTION CERTIFICATION AND LICENSURE 402 West Washington Street, Room W353 Indianapolis, IN 46204-2739 INSTRUCTIONS: 1. Complete original application and attachments. 2. Forward to address in upper right corner of form. I. GENERAL INFORMATION Select type of provider.

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INDIANA ADOPTION MATCHING REGISTRY Date State File Number

Details: INDIANA STATE DEPARTMENT OF HEALTH IC 31-19-19-1 FOR OFFICE USE ONLY Date (month, day, year) State File Number Locator Number INSTRUCTIONS: Participant (s) must be eighteen (18) years of age or older to register for the Indiana Adoption Matching Registry. Participant must be twenty-one (21) years of age or older to obtain Adoption Information.

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SUPPLEMENT TO HEALTH PROGRAM FORM INFANT - TODDLER

Details: The health program will be reviewed to determine compliance with the licensing requirements of 470 IAC 3-4.7. You must send one (1) original program, one (1) original set of attachments to the Family and Social Services Administration, 402 West Washington St., Room W361, Indianapolis, IN 46204.

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WATER TEST KIT ORDER (m/d/y) - Indiana

Details: Make check or money order (no cash or credit cards) payable to Indiana State Department of Health and mail or bring to: ISDH Laboratories – Attn: Containers 550 W. 16th Street, Suite B Indianapolis, IN 46202 (317) 921-5874 FOR ISDH USE ONLY Date Received (m/d/y)_____

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