Indiana State Department of Health
Home Health Agency (HHA) Licensing and Certification Program
Program Overview
Welcome to the homepage for the Indiana State Department of Health Home Health Agency Licensing and Certification Program. The Indiana State Department of Health licenses agencies that provide:
- nursing services;
- physical therapy;
- occupational therapy;
- speech therapy;
- medical social worker;
- home health aide;
- other therapeutic services
to the patient at the patient's temporary or permanent residence. The Indiana State Department of Health inspects state licensed home health agencies for quality of care to citizens of Indiana and to ensure compliance with state law and rules. The Indiana State Department of Health also monitors agencies, on behalf of the Centers for Medicare and Medicaid Services, for quality of care for all citizens in need of those services and to ensure compliance with federal regulations.
Contact the Program
Indiana State Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
(317) 233-7474 (Acute Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Map
Program Manager
Kelly Hemmelgarn
khemmelgarn@isdh.in.gov
(317) 233-7541
(317) 233-7472 [Administrative Assistant]
Report a Complaint or Incident to the ISDH
Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.
Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana State Department of Health of a reportable incident pursuant to the ISDH 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.
Consumer Information
Centers for Medicare and Medicaid Services
Your Medicare Rights and Responsibilities
Advance Directives Resource Center
Out of Hospital Do Not Resuscitate Declaration and Order
Consumer Reports
Home Health Compare (Medicare)
2005 Patient Profile of Home Health Agencies
2004 Patient Profile of Home Health Agencies
2003 Patient Profile of Home Health Agencies
Agency Changes
Select a topic below for instructions on how to submit the change to the department. Please notify the department of changes as they occur at the agency.
- Adding Services
- CMS-1572 (Medicare providers only)
- Adding/Removing Service Area
- Agency address, e-mail, fax, and phone changes
- fax number
- mailing address
- phone number
- physical address
- Agency closure
- Agency name change
- Add “doing business as” (dba) name
- Agency name change
- Legal entity name
- Medicare Voluntary Termination
- Office Hours
- Staff Changes
- Stock Transfer
Branch Information
Select a topic below for information related to Branch questions.
- Adding a Branch location
- Branch Closure
- Branch Relocation (within same County)
- Branch Relocation (new County)
Applications: Applying for Initial Licensure or Change of Ownership
Review all applicable information PRIOR to submission of application to the Department.
Initial Application
To apply for an initial license to operate a home health agency complete the “APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH AGENCY” (SF 4008) and submit with $250.00 licensure fee and other required information to the Indiana State Department of Health.
- Initial Licensure Application Instruction Letter
- Application for License to Operate a Home Health Agency (State Form 4008) Submit all documentation requested on application.
Forms to be completed and returned with the application:
FOR STATE LICENSE AND STATE LICENSE SEEKING MEDICAID:
FOR MEDICARE:
- Initial Certification for Medicare Letter
- CMS LETTER
- Medicare Provider/Supplier Enrollment Applications (Form CMS-855A) Letter
- Process of Initial Medicare Certification
- CMS-Approved Accreditation Organization Contact Information
Medicare Forms:
- Medicare Form Instruction Letter
- Health Insurance Benefit Agreement (Form CMS-1561)
- Assurance of Compliance (Form HHS-690)
- Civil Rights Certification for Medicare Provider Applicants
- Please make sure to complete and submit the “Data Request Checklist”
- Medicare Provider/Supplier Enrollment Application (Form CMS-855A)
Change of Ownership Application
To apply for a Change of Ownership for an existing agency complete the “Application for License to Operate a Home Health Agency” (State Form 4008) and submit with the $250.00 licensure fee, applicable purchase agreement, and other required information to the Indiana State Department of Health.
- Change of Ownership Application Instruction Letter
- Notice of Affiliation
- Home Health Agency Survey Report (CMS-1572)
- Home Health Agency Survey Report State License Only
- Home Health Agencies/Hospice Agencies Geographic Area Served
- Clinical Laboratory Application (HCFA-116) If applicable.
- Copy of the Articles of Incorporation or Certificate of Assumed Business Name signed by the Secretary of State for doing business in Indiana.
- SS-4 or comparable document from the Internal Revenue Service that reflects the corporation name and EIN number.
- $250.00 Licensure Fee
- Copies of current valid Indiana licenses, limited criminal history checks and resumes on new owners, officers, and administrative staff. Please refer to Criminal History Check Information.
- Signed purchase agreement from the buyer and seller with the effective date of transaction.
- Letter of intent from both the buyer/seller on agency letterhead.
For CHOW involving a Medicare CCN please complete the following forms:
Medicare Forms:
- Medicare Form Instruction Letter
- Health Insurance Benefit Agreement (Form CMS-1561)
- Assurance of Compliance (Form HHS-690)
- Civil Rights Certification for Medicare Provider Applicants
- Please make sure to complete and submit the “Data Request Checklist”
- Medicare Provider/Supplier Enrollment Application (Form CMS-855A)
Laws / Rules
- Home Health Agencies State Statute IC-16-27
- Home Health Agencies State Rules (410 IAC 17)
- State Operations Manual-Appendix B (Federal)
General Information
- Title 410 IAC--Article 1 Communicable Disease Control Information
- Universal Precautions and Patients Rights Form
- Advance Directives—Your Right to Decide
- Preparation for Survey
- OASIS Information for Medicare and Medicaid Providers
Licensure Renewals
To renew the agency’s license to operate a home health agency complete the renewal application and submit with the $250.00 licensure fee to the Indiana State Department of Health. In accordance with 410 IAC 17-11-3 an application for renewal of license shall be filed with the department at least sixty (60) days prior, but not sooner than ninety (90) days before, the expiration date of the current license.
If there are changes that occurred at your agency make sure all changes are made on the renewal application. Include all applicable information with the application. The application must be approved and licensure fee received PRIOR to issuance of license.
Submit the $250.00 licensure renewal fee with your renewal application (SF 48851). Make sure check or money order payable to the Indiana State Department of Health. Submit application and $250.00 renewal fee to:
Indiana State Department of Health
Attention: Cashier, 2nd Floor
P.O. Box 7236
Indianapolis, IN 46207
Survey Reporting System (SRS)
Directories
Directory of Home Health Agencies Located in City/County
Directory of Home Health Agencies Serving County
Employment Opportunities
Learn more about Employment Opportunities with the Indiana State Department of Health
Forms
Application for License to Operate a Home Health Agency (State Form 4008) Submit all documentation requested on application.
Branch Questionnaire for a Home Health Agency
Fiscal Intermediaries Information and Forms
Home Health Aide Registry Application
Home Health Aide Registration Renewal Application
Renewal Application for License to Operate a Home Health Agency
Laws and Regulations
Federal Laws and Regulations
Appendix B State Operations Manual
Code of Federal Regulations (CFR) Homepage
State Laws and Rules
Indiana Law and Rules Homepage
Links
Professional Organizations
Indiana Association for Home and Hospice Care
Accreditation Organizations
Accreditation Commission for Health Care, Inc. (ACHC)
American Osteopathic Association
Community Health Accreditation Program (CHAP)
Joint Commission on Accreditation of Hospital Organizations
Quality Improvement 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.
State Government
Indiana Public Access Counselor
Office of Medicaid Policy and Planning (FSSA)
Federal Government
Agency for Healthcare Research and Quality (AHRQ)
Americans with Disabilities Act (ADA)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
Health Care Excel (HCE)
National Patient Safety Foundation
U.S. Small Business Administration
Newsletters
Program Information and Policies
Registry changes effective January 14, 2008
Information on the registry for home health aides, certified nurse aides, and qualified medication aides.
