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Hospital (general) Licensing and Certification Program

A hospital is an institution, a place, a building, or an agency that holds out to the general public that it is operated for hospital purposes and that it provides care, accommodations, facilities, and equipment, in connection with the services of a physician, to individuals who may need medical or surgical services. Any facility that meets the definition of a hospital found in IC 16-18-2-179 must be licensed by the Indiana Department of Health (IDOH).

The IDOH monitors the health care quality of hospitals through the licensure process; IDOH surveyors visit hospitals regularly for licensure inspections or more often if complaints are filed about a hospital.

Report a Complaint or Incident


Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.

Report a complaint

The Incident Report Form is for health care facilities to notify the Indiana Department of Health of a reportable incident pursuant to the IDOH Reportable Unusual Occurrence Policy. The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations. This form is not to be used to file a complaint.

Report an incident

Consumer Information and Reports

Hospital Directories and Reports

Forms

Program Information and Policies

Advisory Letters

Year Number Title
2020 AC-2020-02-HOSP COVID-19 National/State Emergency Hospital Blanket Waiver: Patient Rooms
2020 AC-2020-01 HOSP COVID-19 National/State Emergency Hospital Blanket Waiver: Conversion of Standard Patient Rooms to Negative Pressure Isolation Rooms
2020   Third Emergency Order Granting Temporary Blanket Waivers for Hospitals
2020   Fourth Emergency Order Amending Blanket Waiver on Negative Pressure Isolation Rooms
2019 AC 2019-01 HOSP Standing Waiver for Use of NFPA 101 and NFPA 99 2012 Edition
2014 AC 2014-01 HOSP Patient Self Referral to Hospital Physical Therapy Departments
2012 AC-2012-01 HOSP Cardiographic Technicians and Cardiovascular Technologist Scope of Practice
2011 AC-2011-01 HOSP Standing Waiver for Electronic Verification of Licensure, CSR Registration and DEA Registration
2011 AC-2011-02 HOSP Vein Harvesting by Certified Surgical First Assistants versus Certified Surgical Technologists
2011 HAI-2011-01 Healthcare Associated Infections Reporting Rule

Adding an offsite

To add an offsite to your hospital license, please submit the following documents to Program Director Jennifer Hembree.

  • Request on facility letterhead to add the offsite with the effective date
  • Indiana Department of Health healthcare engineering approval letter for the project
  • AIA substantial completion document
  • Homeland Security Construction Design release document (if a new building or changing occupancy type such as business to healthcare)
  • Fire inspection (this must be from the state or local fire department)

Contact the Program

Indiana Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204 		Program Manager
Jennifer Hembree
317-232-3095 
Jhembree@health.IN.gov
Acute Care Receptionist: 317-233-7474
IDOH Main Switchboard: 317-233-1325		317-232-3095

Laws and Regulations

CMS - Approved Accrediting Organizations

Quality Improvement Organization Information - A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.  QIOs work under the direction of the Centers for Medicare and Medicaid Services (CMS) to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries of the Medicare Trust Fund.