State Form 49560 - Home Health Aide Registry Application
Download a blank fillable State Form 49560 - Home Health Aide Registry Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Form 49560 - Home Health Aide Registry Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset Form
HOME HEALTH AIDE REGISTRY APPLICATION
State Form 49560 (R4 / 5-11)
INDIANA STATE DEPARTMENT OF HEALTH-DIVISION OF ACUTE CARE
*Your Social Security number is requested in accordance with the provision of IC 4-1-8-1. Disclosure is mandatory and this record
cannot be processed without it.
This form indicates that the supervisors of the licensed home health agency or hospice listed
below have determined that this candidate has met the competency requirements listed in
42 CFR 484.36 and should be registered as a home health aide under Indiana Code 16-27-1.5.
I.
Aide Identification
Full Name of Home Health Aide
Residential Street Address
(number and street)
City
County
State
ZIP code
Date of Hire
Aide Telephone Number
(month, day, year)
Date of Birth
Social Security Number*
(month, day, year)
RHHA Registration Number
CNA Registration Number
II.
Record Competency/Skills Check
Name of Organization Conducting Check
City, State and ZIP code
Facility Number
Supervisor’s Name Conducting Check
Date Completed
(month, day, year)
III.
Agency Identification
Program Director’s Name
Name of Home Health Agency
Street Address
(number and street)
City
County
ZIP Code
Facility Number
Agency Telephone Number
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal