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PRINTED: 03/07/2016 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X3) DATE SURVEY COMPLETED 01/04/2016STREET

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1. Go to the Indiana State Department of website.
2. Locate the form you need to fill out.
3. Read the instructions carefully to understand the requirements and guidelines for filling out the form.
4. Gather all the necessary information and documents that are required to complete the form.
5. Fill out the form accurately and legibly, following the specified format.
6. Double-check your entries to ensure accuracy and completeness.
7. Sign and date the form, if necessary.
8. Submit the completed form by either mailing it to the designated address or submitting it online, as specified on the website.
9. Keep a copy of the filled-out form for your records.

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1. Individuals who reside in Indiana and need to interact with the state government.
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3. Job seekers looking for employment opportunities.
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5. Individuals and organizations in need of various permits, licenses, or certifications offered by the state department.
6. Anyone who wants to access and utilize the services, resources, and information provided by the Indiana State Department.

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The Indiana State Department of Health (ISDH) is responsible for promoting, protecting, and enhancing the health of all Hoosiers.

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Healthcare facilities, providers, and other entities are required to file various forms and reports with the Indiana State Department of Health.

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Forms can be filled out electronically on the ISDH website or submitted via mail or fax.

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The ISDH collects data on healthcare services, infectious diseases, and public health trends to monitor and improve the health of Indiana residents.

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Information such as patient demographics, treatment outcomes, disease surveillance data, and healthcare facility data must be reported to the ISDH.