Family and Social Service Administration 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, Scott Huffman at 317-232-4520 or his assistant Marisa Bland at 317-232-0602.
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.
General Agency Forms
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Title |
Form Number |
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450B / PASARR2A Physician Certification for Long-Term Care Services |
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Application for Undue Hardship Waiver (read-only) |
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Approval for Conference/ Training/ Travel |
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BCD 0097 - Work Sheet for CCDF Provider Eligibility Standards Staff Records |
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Budget - Cooperative Agreement Appendix 1-a (read-only) |
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Certification by Physician for Long-Term Care Services And Physical Examination for PASARR Level II |
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Certification - Plan of Care for Inpatient Pschiatric Hospital Services / Determination of Medicaid Eligibility (read-only) |
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Change in Status of Medicaid Hospice Patient (read-only) |
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Claim For Assessment - Preadmission Screening and Annual Resident Review (PASARR) (read-only) |
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Determination of Disability Authorization for Release of Medical Information (read-only) |
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Determination of Disability - Medical Information |
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Determination of Medicaid Disability - Social Summary for Progress Report |
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Equipment - Cooperative Agreement - Appendix I.C. (read-only) |
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Equipment Schedule (read-only) |
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FM 0089 Ledger of Disbursements and Appropriations |
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FM 0411 Claim for Reimbursement_Expenditures - Approved District Plans - Title |
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FM 0412 Certification to the Department of Child Services_Expenditures - Approved District Plans - Title |
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Hospice Authorization Notice For Dually-Eligible Medicare/Medicaid Nursing Facility Residents |
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Hospice Provider Change Request Between Indiana Hospice Providers |
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Medicaid Hospice Discharge |
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Medicaid Hospice Election |
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Medicaid Hospice Plan of Care |
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Medicaid Hospice Revocation (read-only) |
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Medicaid Physician Certification |
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Monthly Reimbursement Claim For Title IV-D Expenditures (read-only) |
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OMPP 0251 Authorization for Examination to Determine Disability for Medical Assistance (read-only) |
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OMPP 0251B Determination of Medicaid Disability Social Summary (read-only) |
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OMPP 450B SA/DE - Nursing Facility Level of Service - State Authorization and Data Entry |
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PASARR Categorical Determination For Short-Term Nursing Facility Care - Certification By Physician for Long-Term Care Services |
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PDP 0001 Indiana's Prescription Drug Program for Seniors - Application for Hoosier Rx (read-only) |
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Personal Services Schedule - Cooperative Agreement Appendix 1-b (read-only) |
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Physician's/Optometrist's Report on Eye Examination (read-only) |
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Profile Information - Hospital Care For The Indigent |
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QMRP Certification for ICF/MR Level of Care Waiver |
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Record of Hearing (read-only) |
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Record of Monthly Time (read-only) |
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Report of Local Travel for Official Travel in Personal Car |
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Report of Overtime |
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Report of Personal Services Expenditure (read-only) |
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Report of Repayment - Expenditures - Approved District Plans - Title |
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Request for Medicaid Expenditures |
Division of Aging Forms
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Title |
Form Number |
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Level II: PASRR / MI Mental Health Assessment |
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QA 1000 - Release of Information Mortality Review |
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Request for Information Mortality Review (read-only) |
Division of Disability and Rehabilitation Forms
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Title |
Form Number |
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450B Attachment for the Aged and Disabled Waiver, the Medically Fragile Children Waiver, the TBI Waiver, and the AL and AFC Waiver |
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Alzheimer's / Dementia Special Care Unit |
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Aplicacion Y Referido DDARS (read-only) |
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Application for Long-Term Care Services (read-only) |
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Application For the Residential Care Assistance Program (read-only) |
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Assistance to Residents in County Homes / Room and Board Assistance Budget and Recommendation (read-only) |
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BCD 0001 Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of their Child |
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BCD 0220 - Data Entry Information Request |
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BQIS 0009 - Notification of Individual's Death |
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BVIS 0004 Vending Facility Monthly Report |
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Certification of Disability for Non-Vocational Rehabilitation Programs (read-only) |
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Chronological Narrative (read-only) |
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Comision De Servicios De Rehabilitacion - Cuestionario Sobre La Satisfaccion Del Cliente (read-only) |
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Commission on Rehabilitation Counselor Certification -Verification of Attendance (read-only) |
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Commission on Rehabilitation Services Customer Satisfaction Survey (read-only) |
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Commission on Rehabilitation Services - Customer Satisfaction Survey - Large Print Version (read-only) |
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Commission on Rehabilitation Services - Satisfaction Survey for Customers with Pre-Lingual Deafness (read-only) |
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Community Vocational/Habilitation Survey |
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Confidential Report of Blindness or Visual Impairment |
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Consent For Disclosure of Information (read-only) |
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Continuing Education Units For The Indiana Interpreter Certificate (read-only) |
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DDARS Referral and Application (read-only) |
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Definition of Specialized Services for PAS/ARR (read-only) |
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DHHS 0003 Deaf and Hard of Hearing Services Interpreter Service Program (ISP) / Social Services Block Grant (SSBG) Application and Services Registration (read-only) |
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DHHS 0004 Indiana Interpreter Certificate Application (read-only) |
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DHHS 0008 Educational Indiana Interpreter Certificate Application (read-only) |
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DHHS 0015 Educational Indiana Interpreter Certificate Application for Renewal (read-only) |
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DHHS 0016 Indiana Interpreter Certificate Application for Renewal (read-only) |
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DHHS 0017 Application for Replacement of Indiana Interpreter Certificate or Identification Card |
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DHHS CEU Sponsorship Approval |
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Disclosure For Housing With Services Establishments |
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Employment Questionnaire (read-only) |
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Financial Aid Communications (read-only) |
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How Are We Doing? (VRS 0009) (read-only) |
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How Are We Doing? (VRS 0015) (read-only) |
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Incident Report (read-only) |
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Incident Report |
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Indiana PAS/PASRR Program Fax Cover Sheet (read-only) |
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Indiana PASARR/MI Program - CMHC ARR Referral Checklist (read-only) |
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Indiana PASARR Program - Dementia Assessment Checklist (read-only) |
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Indiana PASRR Program - Screen For Depression (read-only) |
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Information Required in an Emergency (read-only) |
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Interpreter Service Program |
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Monthly Report of Vending Income (read-only) |
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MRC Release of Information for DDRS (read-only) |
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Notice of Action |
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PASARR Level I - Identification Evaluation Criteria - Certification by Physician for Long-Term Care Services |
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Plan of Care / Cost Comparison Budget For the Aged and Disabled Waiver (read-only) |
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Plan of Care / Cost Comparison Budget for the AL and AFC Waiver (read-only) |
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Plan of Care / Cost Comparison Budget for the Autism Waiver (read-only) |
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Plan of Care / Cost Comparison Budget for the Medically Fragile Children Waiver (read-only) |
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Plan of Care / Cost Comparison Budget for the TBI Waiver (read-only) |
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Plan of Care (multi) |
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Post-Transition Quality Assurance Checklist (read-only) |
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Post-Transition Quality Assurance Checklist |
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Post-Transition Quality Assurance Checklist - Guidelines (read-only) |
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Post-Transition Quality Assurance Checklist - Guidelines |
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Pre-Transition Quality Assurance Checklist (read-only) |
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Pre-Transition Quality Assurance Checklist |
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Pre-Transition Quality Assurance Checklist - Guidelines (read-only) |
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Pre-Transition Quality Assurance Checklist - Guidelines |
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Provider Standards Agency Survey |
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Recommendation of County Office - Assistance to Residents in County Homes - Room and Board Assistance (read-only) |
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Referral for Services for the Blind and Visually Impaired (read-only) |
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Report of Hearing and Ear Assessment (read-only) |
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Social Services Block Grant |
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Statement of Book Expense (read-only) |
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Support Service Expense Statement (read-only) |
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Survey of Residential Services & Supports |
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Transmittal for Medicaid Level of Care Eligibility (read-only) |
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Worksheet for Data Entry - Termination or Denial (read-only) |
Division of Family Resources Forms
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Title |
Form Number |
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6 Month (Or Other Planned) IFSP Review Cover Sheet |
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Acuerdo de Responsibilidad Personal |
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Affidavit For Replacement of Food Stamp Benefits (read-only) |
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Annual IFSP Checklist |
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Applicant Job Search Referral (read-only) |
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Applicant Job Search Rights and Responsibilities (read-only) |
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Application and Claim for Funds to Defray Burial Costs - Medicaid Aged, Blind and Disabled Recipients |
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Application for Assistance - Part 3 - Client Certification and Assignment (read-only) |
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Application for Hoosier Healthwise for Children and Pregnant Women (read-only) |
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Application for Voluntary Certificate of Recognition |
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Aviso De Imcumplimiento Con Los Requisitos De Impact (Empleo Y Capacitación) |
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BCD 0005 - Provider Reciprocal Consent to Release and Share Information |
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BCC 0012 - Attestation Statement (read-only) |
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BCC 0025 - Application for Child Care Home Variance or Waiver (read-only) |
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BCC 0032 - Checklist for Unlicensed Register Child Care Ministries Sanitation Survey (read-only) |
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BCC 0036 - History of Immunizations |
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BCC 0079 Licensed Child Care Center / Home Monthly Report as Required by IC 12-17.2.2-1.5 |
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BCC 0080 Licensed Child Care Center / Home Consent |
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BCC 0091 - Child Care Development Fund (CCDF) Provider Eligibility Standards (PES) Checklist (read-only) |
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BCC 0095 - Application / Decline / Recommendation for Denial for Non-Compliance |
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BCC 0100 - Proposed Multiple Residences for Child Care Home Design Professional Statement (read-only) |
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BCC 0101 - Child Care Home Certification of Residential Structure (read-only) |
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BCC 0310 - DFR / CCDF Referral (read-only) |
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BCC 0312 - Provider Response Document |
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BCC 0320 - Review / Assessment for Child Care Centers (read-only) |
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BCC 0330 - Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs (read-only) |
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BCC 0331 - Child Care Area |
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BCC 0410 - Child Care: Consent for Release of Information |
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BCD 0108 General Reciprocal Consent to Release and Share Information |
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BCD 0110 - Outcome Review |
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BCD 0111 - Request For Authorization / Meeting Minutes (read-only) |
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BCD 0211 - Ongoing Record |
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Behavioral/Physical Health Coordination |
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Changes To The IFSP |
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Checklist for Child Care Centers Health/Foods/Sanitation/Survey |
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Child Care Center Narrative (read-only) |
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Claim - Voucher |
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Client Attendance Report - IMPACT Service Provider |
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Community Work Experience Program Job Request |
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Cover Letter For FI 0014 and FI 0065 |
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Documentation of Child Transfer to Another County |
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Employability Plan (read-only) |
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Family Information Update |
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FI 0009 - Notice Regarding Rights and Responsibilities (read-only) |
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FI 0009S - Aviso Relacionado con los Derechos y las Responsabilidades (read-only) |
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FI 0019 - Request for Information from Indiana Department of Revenue |
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FI 0033 - EBT Daily Log For Card Issuance |
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FI 0425B Case Disposition Regarding Exemption from Cooperation in Child Support and/or Medical Support Enforcement |
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FI 2009 Medical Assignment Good Cause Notice (read-only) |
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FI 2033 Application for Medicare Savings Program (QMB, SLMB, QI) |
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FI 2400 Application for Assistance - Part I - Food Stamps, Cash Assistance, Health Coverage (read-only) |
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FI 2400S Solicitud para Asistencia / Cupones para Alimentos, Asistencia Financiera, Cobertura de Salud (read-only) |
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FI 2420 Report of Change |
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FI 2430 - Proof of Eligibility |
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FI 2511 - Consent for Release of Information |
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FI 2511S - Consentimiento para Revelar of Información |
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FI HCI 0001 - Application for Hospital Care For The Indigent |
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First Steps 30 Month Notice to Local Education Agency (LEA) |
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First Steps Cost Participation Co-Payment (read-only) |
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First Steps Cost Participation Financial Deduction Worksheet (read-only) |
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First Steps Documentation of Team Discussion |
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First Steps Early Intervention System Documentation Of Receipt Of Rights / Consent To Proceed / Permission To Assess (read-only) |
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First Steps Part C Eligibility Determination Statement (read-only) |
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First Steps Private Medical Insurance Consent (read-only) |
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First Steps Transitional Meeting Minutes |
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HIP 2514 Authorization for Release of Medical Information - Healthy Indiana Plan (read-only) |
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HIP 2515 Application for Healthy Indiana Plan (read-only) |
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HIP 2515S Aplicación Plan de Salud de Indiana (read-only) |
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HIP 2518 Healthy Indiana Plan - POWER Account Payment Status (read-only) |
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HIP 2519 Report of Change - Healthy Indiana Plan (read-only) |
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HIP 2521 Notice of Action - Healthy Indiana Plan (read-only) |
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IMP 0002 Community Work Experience Program Agreement (CWEP) (read-only) |
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IMP 0029 - IMPACT Memorandum |
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IMP 0032 Impact Responsibilities, Sanctions, and Rights / Voluntary Clients and TANF Minors (read-only) |
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IMP 0033 Impact Responsibilities, Sanctions, and Rights / Mandatory Adult Clients (read-only) |
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IMP 2210 Notice of Noncompliance with Impact (Employment and Training) Requirements |
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IMPACT Client Agreement (read-only) |
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IMPACT Referral (read-only) |
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IMPACT Report - Family Case Coordinator Monthly Referrals (read-only) |
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IMPACT Responsibilities, Sanctions, and Rights - Mandatory Adult Clients (read-only) |
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IMPACT Vocational or Job Skills Training -- Financial Information (read-only) |
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Indiana First Steps Early Intervention System - Exit Summary |
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Indiana First Steps Early Intervention System - Family Interview |
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Individualized Family Transition Plan |
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Initial Appointment for IMPACT |
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Initial Assessment of Employability |
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Job Search Verification (read-only) |
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Master Job Application (read-only) |
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Notice of Discontinuance of IMPACT Services |
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OMPP 0046 - Request To Access Indiana Health Coverage (read-only) |
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OMPP 0046 - Request To Access Indiana Health Coverage |
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OMPP 0047 - Personal Representative Authorization (read-only) |
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OMPP 0047 - Personal Representative Authorization |
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OMPP 0048 - Client Member Authorization (read-only) |
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OMPP 0048 - Client Member Authorization |
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OMPP 0050 - Report On Complaint Filed (read-only) |
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OMPP 0050 - Report On Complaint Filed |
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OMPP 0051 - Revocation of Authorization (read-only) |
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OMPP 0052 - Member Access Request (read-only) |
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OMPP 0053 - Member Accounting Request (read-only) |
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Parent's Notice (read-only) |
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Personal Responsibility Agreement (read-only) |
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Physician's Health Care Summary - First Steps Early Intervention System - Children's Special Health Care Services |
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Prior Approval Request |
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Private Medical Insurance Supplement (read-only) |
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PYL 2625: Report of Child Protective Overtime (read-only) |
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Reason For Delay of IFSP |
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Record of Financial Eligibility Budget for Hoosier Healthwise |
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Record of IMPACT Attendance (read-only) |
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Record of IMPACT Attendance - Multiple Activities (read-only) |
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Report of Job Placement -IMPACT Service Provider (read-only) |
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Request for Administrative Hearing |
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Request for Authorization for Audiology Services |
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Request for Authorization for Transition Meeting/Transition Checklist |
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Request for Student Income and Expenses |
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Request for Transportation (read-only) |
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Researching the Occupation - Interview Questionnaire (read-only) |
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Researching Vocational or Job Skills Training Program (read-only) |
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Service Change To The IFSP Checklist |
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Solicitud Para Asistencia - Parte 3 - Certificacion del Cliente y Asignacion (read-only) |
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Solicitud Para Hoosier Healthwise Para Ninos & Mujeres Embarazadas (read-only) |
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Supplement to Health Program Form, Infant - Toddler (read-only) |
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Transition Meeting Notification |
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Written Nutrition / Food Service Program - Child Care Centers (read-only) |
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Written Nutrition / Food Service Program - Infant / Toddler Child Care Centers (read-only) |
Office of General Counsel Forms
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Title |
Form Number |
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Treatment Team's Recommendation for Leave of Absence for Criminally Involved Persons (read-only) |
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Treatment Team's Recommendation for Leave of Absence to Out-of-State Destination (read-only) |
Division of Mental Health and Addiction
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Title |
Form Number |
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Application For Certification or Licensure |
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Application For Long Term Care Services - Mental Health Hospitalised Waiver (read-only) |
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CS 0023 Application for OPIOID Treatment Program (OTP) Approval |
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CS 0024 - Required Documentation for Applicants for Approval as New OPIOID Treatment Programs |
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CS 0027 - Documentation of Direct Services Providers |
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Facility Facts Record |
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Notice Of Action-Home And Community Based Services / Serious Emotional Disturbance Behavior (read-only) |
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Plan Of Care/Cost Comparison Budget Children With Serious Emotional Disturbances (SED) Waiver |
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Provisional Plan Of Care - Children With Serious Emotional Disturbance Medicaid Waiver (read-only) |
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Report of Incident / Injury |
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State Hospital Referral |
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Statement of Freedom of Choice (read-only) |
Larue Carter Memorial Hospital Forms
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Title |
Form Number |
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Interim Psychological Evaluation |
Madison State Hospital Forms
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Title |
Form Number |
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