Mobile Out-of-State Health Care Entity Registration Program
Program Overview
The Mobile Out-of-State Health Care Entity Registration Program registers any entity that is from out of state, licensed or registered under the laws of another state, foreign country, or province of a foreign country and provides health care services in a mobile facility or temporary location for a short period of time in Indiana.
Contact the Program
Indiana State Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
(317) 233-7474 (Acute Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Map
Program Manager
Darlene Earls
dearls@isdh.in.gov
(317) 233-7492
(317) 233-7742 [Secretary]
Report a Complaint or Incident to the ISDH
Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.
Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana State Department of Health of a reportable incident pursuant to the ISDH Reportable Unusual Occurrence Policy. The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations. This form is not to be used to file a complaint.
Facility Changes
- Address, phone and fax changes
- physical addesss
- mailing address
- phone number
- fax number
- email address
- Certification of Registration Renewal
- Facility closure
- Facility hours
- Facility name change
- add "doing business as" (dba) name
- Facility name change
- legal entity name
- Staff Changes
- manager
- Stock Transfer
Applications: Initial Certificate of Registration or Change of Ownership
Initial Application
To apply for an initial certificate of registration to operate an out of state mobile health care entity complete the “Application For Registration To Operate An Out of State Mobile Health Care Entity (SF 53398)" and submit with all required information to the Indiana State Department of Health.
Change of Ownership Application
To apply for a change of ownership for an existing facility agency complete the “Application for Registration to operate an out of State Mobile Health Care Entity (SF 53398)" and submit with the purchase agreement and all required information to the Indiana State Department of Health.
Topics
Click on the topics below for the applicable instruction letter, application, laws and rules for initial registration or change of ownership application process. Review all applicable information prior to submission of application to the Department.
Instruction Letters
Select the “Initial Certificate of Registration Application Instruction Letter” for an initial certificate of registration application or the “Change of Ownership Application Instruction Letter” for a change of ownership application.
- Initial Certificate of Registration Application Instruction Letter
- Change of Ownership Application Instruction Letter
Initial or Change of Ownership Application Form
Laws/Rules
- Out of State Mobile Health Care Entity State Statute (Law) IC 16-41-42.1
- Out of State Mobile Health Care Entity State Rules 410 IAC 15.1
Certificate of Registration Renewal
To renew the facility’s registration to operate an Out of State Mobile Health Care Entity complete the renewal application and submit to the Indiana State Department of Health.Click on the topics below for the application and instructions on how to complete the certificate of registration renewal application.
- Renewal Application for Registration to Operate an Out of State Mobile Health Care Entity (SF 55086)
- Instruction Letter
Employment Opportunities
Learn more about Employment Opportunities with the Indiana State Department of HealthLaws and Regulations
State Laws and Rules
IC 16-41-42.1; Registration of Out-of-State Mobile Health Care Entities
410 IAC 15.1; Out of State Mobile Health Care Entity State
Indiana Law and Rules Homepage
Links
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