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ISDN Hospital Service Report State Form 49476 (R /702) IC 16216Status: Finalized I. Hospital Information Hospital PREVIEW LAGRANGE HOSPITAL Name: Provider #: 151323 City: LaGrange County: LaGrange
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01
To fill out the ISDH Hospital Service Report, follow these steps: 1. Start by entering the date of service at the top of the form.
02
Provide the name and contact information of the hospital or healthcare facility where the service was provided.
03
Enter the patient's information, including their name, date of birth, and any relevant identification numbers.
04
Specify the type of service provided, such as inpatient care, outpatient surgery, or emergency room visit.
05
Provide a detailed description of the services rendered, including any procedures performed, medications administered, and diagnostic tests conducted.
06
Indicate the start and end times of the service, as well as the total duration.
07
Include any additional information or notes that may be relevant to the service provided.
08
Enter the name and contact information of the healthcare provider or physician responsible for the service.
09
Review the completed form for accuracy and completeness before submitting it to the appropriate authorities.

Who needs isdh hospital service report?

01
The ISDH Hospital Service Report is typically required by healthcare facilities, hospitals, and physicians. It is used to document and report the services provided by a hospital or healthcare facility to patients. This report may be necessary for record-keeping, billing purposes, insurance claims, or compliance with regulatory requirements.
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The ISDH hospital service report is a document that hospitals are required to submit to the Indiana State Department of Health detailing the services provided.
All hospitals operating in Indiana are required to file the ISDH hospital service report.
The ISDH hospital service report can be filled out online through the ISDH website or submitted via mail using the provided form.
The purpose of the ISDH hospital service report is to track and monitor the services provided by hospitals in Indiana.
The ISDH hospital service report requires information such as patient demographics, services provided, and outcomes.
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