Providers

• Adoption Matching Program: Birth Parent Contact Preference (State Form 56535)
• Record of Adoption State Form 5438
• July 1, 2010 and after - Hospital Paternity Affidavit Form - to be completed by the Hospitals/Birthing Centers only
  • Paternity Affidavit - Hospital Use (State Form 44780)
• July 1, 2010 and after - Local Health Department Paternity Affidavit Form - to be completed by the Local Health Department only
  • Local Health Department Paternity Affidavit – Child More than 60 Days Old
  • Local Health Department Paternity Affidavit – Child Less than 60 Days Old
• Application for Search and Certified Copy of Birth Record - State Form 49607 (R10 / 9-18) Word | PDF

• Adult HIV/AIDS Confidential Case Report
• Animal Bites Report - State Form 14702 (R3/4-04)
• Confidential Report of Communicable Diseases - State Form 43823
• Hepatitis B and Delta Hepatitis Case Investigation - State Form 52587 (R/11-09)
• Hepatitis C Case Investigation - State Form 52588 (R/11-09)
• Indiana Confidential Sexually Transmitted Disease Report - State Form 56459
• Perinatal Hepatitis B Case Investigation - State Form 52589 (2-06)
• Pregnant Women HIV Test History and Assessment - State Form 52048 (R/3-11)
• TB - Monthly TB Follow-Up Report - State Form 48092
• TB - Report of Latent TB Infection - State Form 49894
• TB - Report of Tuberculosis - State Form 14058
• TB - Tuberculosis Waiver Request - State Form 46595
• Vaccine Administration Record, State Form 54642 (05-06)

• Application for Search and Certified Copy of Death Record - State Form 49606 (R8 / 9-18) Word | PDF

• National Provider Identifier (NPI) Information

• Temperature Log for Vaccines (Celsius)
• Temperature Log for Vaccines (Fahrenheit)
• Refusal To Vaccinate
• Screening Questionnaire for Adult Immunization
• Screening Questionnaire for Child and Teen Immunization
• Vaccine Administration Record for Adults
• Vaccine Administration Record for Children and Teens
• Vaccine Adverse Event Reporting System
• Vaccine Information Statements Q and A

• Adoption History Fee Transmittal-SF27337
• Certified Court Order to Change Birth Record to Establish Paternity or Other Changes to Birth Record - State Form 47970 (R6/7-12)
• Putative Father Registry Fee Transmittal-SF46784

• Review all Clinical and Environmental

• Application for Search for Certified Record of Marriage - State Form 54764 (R4 / 10-18)

• Application for Radiology License (Not License Renewal)
• Application for Approval of Radiology Program
• Application for Proficiency Certification for Limited Radiographer
• Board Form X
• Radioactive Materials Registration Application
• Radiation Machine Registration Application
• Renew or Verify a License or Registration
  • All licensed individuals (Nuclear Medicine, Radiation Therapy and Radiologic Technologists) may renew their licenses online through the License Express online licensing system
  • Online renewal is now available for individuals that hold licenses in multiple categories (e.g. Nuclear Medicine and Radiologic Technology). Please pay for each separately. Notify our office at MedicalRadiology@isdh.IN.gov that you have renewed more than one license. We will initiate the process of refunding the appropriate fees.

• Vaccine Administration Record, State Form 54642 (05-06)

Terminated pregnancies are reported to the Indiana Department of Health by performing physicians in accordance with Indiana Code 16-34-2.

Terminations must be submitted electronically in accordance with Indiana Code 16-34-2-5.5. The reporting system was developed for the purpose of reporting terminations in an electronic format. All physicians that will be submitting terminated pregnancy reports in the system must be registered; to register, users must submit a completed User Agreement Form. A training presentation is available to assist users in learning the system.

• TPR Submission Guidance (updated 7/19/2023)
• Enrollment Steps
• TPR System Training
• Database Registration of Indiana's Vital Events (DRIVE)
• DRIVE ITOP User Guide
• Abortion Complications Report
  • Instructions included at the end of the document.