Department of Health Forms
To search this catalog: From the toolbar in the Edit menu, select "Find". When the Find search box appears, enter a keyword or form number. The first search result will display with the keyword or number highlighted, at the top of the page. Click "Find next" until the desired form is highlighted.
For forms labeled "PDF", the free Adobe Acrobat Reader software is required to view and in some cases fill them out. Forms in other formats (MS Word, MS Excel, etc) are indicated where appropriate.
To open a form once you have chosen it, click on the linked State Form Number (such as 01365.pdf).
For questions about individual forms, please contact this agency's forms coordinator, Joannie Johnson at 317-234-4406.
For questions about how to use this catalog, or to inform us of a technical problem, please send e-mail to the Forms Management Division.
Forms marked "read-only" cannot be filled in on your computer. They must be printed out and filled in by hand or typewriter.
|
Title |
Form Number |
|
Adoption History Registration Program Birth Parent Nonrelease Form (read-only) |
|
|
Agreement for Release of Vital Statistics Data Tapes Containing Confidential Information |
|
|
Annual Birthing Center Report |
|
|
Annual Nonprofit Hospital Community Benefit Statement (read-only) |
|
|
Annual Report of Comprehensive Long Term Care Facility (read-only) |
|
|
Application & Approval for Admission (read-only) |
|
|
Application Checksheet For Lead Contractor |
|
|
Application for Approval of the Qualified Medication Aide Course (read-only) |
|
|
Application for Construction Permit (read-only) |
|
|
Application for Construction Permit for an Acute Care Facility (read-only) |
|
|
Application for Construction Permit For Child Care Facility (read-only) |
|
|
Application for Construction Permit For Long-Term Care Facilities (read-only) |
|
|
Application for Construction Permit for Private Mental Health Institutions (read-only) |
|
|
Application for Construction Permit For School Facilities (read-only) |
|
|
Application For Duplicate Lead License |
|
|
Application for Individual Lead License (read-only) |
|
|
Application for Individual Lead License |
|
|
Application for Insulin and Township Claim (read-only) |
|
|
Application For Lead-Based Paint Training Course Provider Approval (read-only) |
|
|
Application For Lead-Based Paint Training Course Provider Approval |
|
|
Application For Lead Contractor License (read-only) |
|
|
Application For Lead Contractor License |
|
|
Application for License Approval to Operate a Hospice Program (pursuant to IC 16-25-3) (read-only) |
|
|
Application for License to Operate a Birthing Center |
|
|
Application for License to Operate a Blood Center |
|
|
Application for License to Operate a Health Facility |
|
|
Application for License to Operate a Health Facility |
|
|
Application for License to Operate a Home Health Agency (pursuant to IC 16-27 and 410 IAC 17) (read-only) |
|
|
Application for License to Operate a Hospital Pursuant to IC 16-21-2 |
|
|
Application for License to Operate an Abortion Clinic |
|
|
Application for License to Operate an Ambulatory Outpatient Surgical Center |
|
|
Application for License to Operate a Personal Services Agency |
|
|
Application for Marriage License (read-only) |
|
|
Application for Permit to Disinter, Remove, and Reinter Human Remains |
|
|
Application For Plan Review (read-only) |
|
|
Application for Radiology License or Permit (read-only) |
|
|
Application for Radon Tester/Mitigator Certification (read-only) |
|
|
Application for Registration as Manufacturer, Processor, Repackager or Wholesale Distributor of Food, Drugs, or Cosmetics (read-only) |
|
|
Application for Registration to Operate an Out of State Mobile Health Care Entity |
|
|
Application for Renewal of Health Facility License (read-only) |
|
|
Application for Search and Certified Copy of Birth Record (read-only) |
|
|
Application for Search and Certified Copy of Death Record (read-only) |
|
|
Application - Senior Farmers' Market Nutrition Program (read-only) |
|
|
ASC Utilization Report (read-only) |
|
|
Bed Change Request (read-only) |
|
|
Bed Inventory Sheet (read-only) |
|
|
Bioterrorism Environmental Sample Submission |
|
|
Branch Questionnaire for a Home Health Agency |
|
|
Certified Nursing Aide Private Care (read-only) |
|
|
Chemical Examination of Water |
|
|
Confidential Report of Communicable Diseases (read-only) |
|
|
CSHCS Enrollment Packet (read-only) |
|
|
Enteric Bacteriology |
|
|
Enteric Reference Culture |
|
|
Fax/Incident Report (read-only) |
|
|
Fireworks Injury Reporting (read-only) |
|
|
Health Officials/Pools & Spas/Beaches & Lakes Report |
|
|
Home Health Aide Registry Renewal |
|
|
Home Health Report (read-only) |
|
|
Hospital Fiscal Report (read-only) |
|
|
Hospital Service Report (read-only) |
|
|
Independent Verification of Assets and Liabilities (read-only) |
|
|
Indiana Adoption History Registration - Identifying Information Consent (read-only) |
|
|
Indiana Adoption History Registration - Nonidentifying Information Consent (read-only) |
|
|
Indiana Adoption Medical History Report (read-only) |
|
|
Indiana Health Care Professional Recruitment and Retention Fund - Student Loan Repayment Application |
|
|
Indiana Putative Father Registration (read-only) |
|
|
Individual User Agreement (read-only) |
|
|
Influenza Lab Submission (read-only) |
|
|
ISDH Literature Order (read-only) |
|
|
Local Board of Health Membership Roster |
|
|
Logistics Storage Center Request to Store |
|
|
Monthly Tuberculosis Follow-Up Report |
|
|
Mosquitoborne Encephalitis Case Investigation |
|
|
Mycobacteriology Test Request |
|
|
Mycology Test Request |
|
|
National Provider Identifier (NPI) Information |
|
|
National Provider Identifier (NPI) Information |
|
|
Notice of Transfer or Discharge (read-only) |
|
|
Notice of Transfer or Discharge Request For Hearing (read-only) |
|
|
Notification of Blood or Body Fluid Exposure |
|
|
Notification of Ineligibility - Senior Farmers' Market Nutrition Program (read-only) |
|
|
Notification of Lead Abatement Activities (read-only) |
|
|
Notification of Lead Abatement Activities (read-only) |
|
|
Nurse Aide Registry CNA Renewal (read-only) |
|
|
Official Indiana Animal Bites Report (read-only) |
|
|
Operator Response to Inspection (read-only) |
|
|
Operator Response to Inspection (Food Protection Program) (read-only) |
|
|
Parasitology |
|
|
Parasitology |
|
|
Perinatal Hepatitis B Screen |
|
|
Plan Review Questionnaire (Food Protection Program) (read-only) |
|
|
Primary Health Care - Community Health Center - Request for Proposal (read-only) |
|
|
Private Water Supply Report (read-only) |
|
|
Professional/Consultant Documentation for ICF/MR (read-only) |
|
|
Provider Request for Supplies |
|
|
Provider Request for Supplies - Marion Co. |
|
|
Provider Request for Supplies - Vanderburgh Co. |
|
|
Provider Site Enrollment Agreement (read-only) |
|
|
Provider Survey Questionnaire (read-only) |
|
|
Provider Survey Questionnaire (read-only) |
|
|
Public Water System Report |
|
|
Qualified Mental Retardation Professional (QMRP) (read-only) |
|
|
Rabies Examination |
|
|
Recall Audit (read-only) |
|
|
Record of Adoption (read-only) |
|
|
Record of Adoption |
|
|
Record of Marriage (read-only) |
|
|
Reference Bacteriology Culture Identification |
|
|
Registration Application for a Retail Food Establishment (read-only) |
|
|
Registration for Lead-Based Paint Third-Party Examinations |
|
|
Regulatory Services Informal Dispute Resolution (IDR) Record (read-only) |
|
|
Reimbursement For Travel To/From Approved Providers For 50 Miles Or More Roundtrip (read-only) |
|
|
Remediation Follow-up Report on Environmental Investigations (read-only) |
|
|
Renewal Application For License to Operate a Home Health Agency (read-only) |
|
|
Renewal Application For License Approval To Operate A Hospice (read-only) |
|
|
Report of Treatment for Latent TB Infection (read-only) |
|
|
Report of Tuberculosis (read-only) |
|
|
Request for Administrative Forms & Information Materials |
|
|
Request for TB Drugs (read-only) |
|
|
School Hearing Screening Report |
|
|
School Scoliosis Screening Report |
|
|
Summary Report on Measles & Polio Immunizations Sixth Grade Students Enrolled in School (read-only) |
|
|
Summary Report on the Immunization Status of Kindergarten Students Enrolled in School (read-only) |
|
|
Summary Report on the Immunization Status of First Grade Students Enrolled in School (read-only) |
|
|
Supplementary Information to Federal Application - End Stage Renal Disease (ESRD) Facility |
|
|
Supplementary Information to Federal Application Rural Health Clinic (RHC) (read-only) |
|
|
Surgery for the Treatment of Morbid Obesity - Follow-up Report |
|
|
Surgery for the Treatment of Morbid Obesity - Initial Report |
|
|
Syphilis Test Requestt |
|
|
TB Hospital Reimbursement Claim (read-only) |
|
|
Tuberculosis Contact Investigation Report (read-only) |
|
|
Tuberculosis Waiver Request (read-only) |
|
|
Unlicensed Facility Request for CD Aide Renewal Program (read-only) |
|
|
Varicella (Chickenpox) Disease Surveillance Monthly Report (read-only) |
|
|
Varicella Sentinel Surveillance System - Enrollment (read-only) |
|
|
Video Order (read-only) |
|
|
Virology / Immunology Request |
|
|
Water Test Kit Order |
- How do I find the state form I need?
- What kind of records can I find in the Indiana State Archives?
- How can I obtain copies of state records?
- How long must a state or local government agency keep its records?
- How do I order copies of records from the Indiana State Archives?
- How should a state agency transfer records to the State Records Center for stora...
- Browse the State Archives Collections
- Find a State Form
- Learn How Long My Agency Must Keep Records
- Find the Records or Forms Coordinator For My Agency
- Microfilm or Image My Agency's Records
- Send My Agency's Records to the Records Center
- Send My Agency's Records to the State Archives
- Prevent or Report a Public Records Emergency
- Arrange a Tour or Attend a Training Session
