Form 49560 - Home Health Aide Registry Application
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2Home Health Aide Registry Application
State Form 49560 (11-99)
I. Applicant Information
*Your Social Security Number is being requested by this State Agency in accordance with 42 CFR 483.156(c)(1)(ii).
Disclosure is mandatory, and this application cannot be processed without such.
_______________________________________________
__________________________________
Name of Applicant
Social Security Number
_______________________________________________
__________________________________
Street Address
Phone Number
______________________________________________________________________________________
City
State
Zip + 4
_______________________________________________
__________________________________
Date of Birth
QMA/CNA Number (if applicable)
_______________________________________________
__________________________________
Name of Agency Where Employed
Date of Hire
_______________________________________________
__________________________________
Street Address of Agency
Phone Number of Agency
______________________________________________________________________________________
City
State
Zip + 4
I certify subject to the penalties of perjury that the information on this form is true and correct.
_____________________________________________________
____________________________
Applicant’s Signature
Date
II. Course Information: 16-Hour Classroom
______________________________________________________________________________________
Name of Entity Presenting Instruction
Facility Number
______________________________________________________________________________________
Street Address
______________________________________________________________________________________
City
State
Zip + 4
______________________________
___________________________________________________
Date Completed
Name of Program Director
License Number
I certify subject to the penalties of perjury that the above named individual completed the 16 hours of classroom instruction in
accordance with 410 IAC 17-6-1(e), from the above named agency; and that the presenting agency has not been precluded from
offering such instruction in the previous twelve (12) months in accordance with 410 IAC 17-6-1(f).
_____________________________________________________
____________________________
Program Director’s Signature
Date
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