Forms.in.gov

IARA: State Forms Online Catalog

WebFind and download various state forms for Indiana, such as adoption, tax, health, and vital records. Easy and convenient online catalog.

Actived: 3 days ago

URL: https://forms.in.gov/Download.aspx?id=10022

BRANCH QUESTIONNAIRE FOR A HOME HEALTH AGENCY

WebContact for Assistance. If you have any questions, please contact the Program Coordinator at the Indiana State Department of Health Division of Acute Care at 317-233-7302, or …

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APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH …

WebThe home health agency must: (1) be authorized by the secretary of state to conduct business in Indiana; and (2) have a branch office located in Indiana. Application for a …

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Instruction for completion: Health Programs

WebIAC 3-4.7.84. All items in the forms must be carefully studied and completed by the authorities responsible for the development of the health program. A number of …

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HEALTH CARE PROGRAM – CHILD CARING INDIANA …

WebE-mail address of person completing form. SECTION 1 – HEALTH PROGRAM. Arrangements have been made for the consulting physician or nurse practitioner below …

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AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE

WebAUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE. AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE. State Form 55366 (R2 / 12-14) / DFR …

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IARA: State Forms Online Catalog

WebIARA: State Forms Online Catalog

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RENEWAL APPLICATION FOR LICENSE APPROVAL TO …

WebAll questions on this application must be answered completely and legibly with printed or typed script with supporting documentation attached when applicable. Incomplete or …

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HEALTH CARE PROGRAM FOR CHILD CARE HEALTH RECORD

WebHEALTH 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 …

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HEALTH CARE PROGRAM FOR CHILD CARE FAMILY AND …

WebHEALTH CARE PROGRAM FOR CHILD CARE RECORD OF ADULT PHYSICAL HEALTH EXAMINATION State Form 49970 (R6 / 7-19) Name Address (number and street, city, …

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SUPPLEMENT TO HEALTH PROGRAM FORM INFANT

WebInstructions for completion: Supplemental Health Program forms are to be used by Child Care Centers with children of ages from six (6) weeks to two (2) years (Infant-Toddler) …

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WATER TEST KIT ORDER (m/d/y)

Webe) ____No charge (Fluoride) sample kits for Municipal Water Utilities and Schools only with no shipping / handling. Make check or money order (no cash or credit cards) payable to …

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CSHCS ENROLLMENT PACKET THIS PACKAGE CONTAINS …

WebState Form 49006 (R9 / 2-17) Indiana State Department of Health Children’s Special Health Care Services. THIS PACKAGE CONTAINS CONFIDENTIAL INFORMATION PER 410 …

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RENEWAL APPLICATION FOR LICENSE TO OPERATE A HOME …

WebApplicant Entity (Owner / Operator) Type or write in owner’s name below. If a change of ownership occurred, you must request in writing a change of ownership application, …

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Guidance for Completing State Form 9966

WebStatutory Authority: I.C. 31-19-2-7. Time of Filing: The original copy of this form shall be filed with the Clerk of Court accompanying the petition, or within sixty (60) days of the filing of …

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Thank you for your interest in the Medicare Savings Program.

WebState Form 49228 (R6 / 4-19) To apply, please fill out both sides of the attached application. If there are parts that you do not understand, it is okay to leave them blank. However, …

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SWIMMING POOL RECORD OF OPERATION

WebState Form 12279 (R5 / 4-11) 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. …

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