Free 49560.pdf - Indiana

HOME HEALTH AIDE REGISTRY APPLICATION
State Form 49560 (R3 / 9-08)

INDIANA STATE DEPARTMENT OF HEALTH-DIVISION OF ACUTE CARE

*Your Social Security number is requested in accordance with the provision of IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

This form indicates that the supervisors of the licensed home health agency or hospice, listed below have determined that this candidate has passed a competency evaluation and should be registered as a home health aide under Indiana Code 16-27-15. I. Aide Identification

Full Name of Home Health Aide Residential Street Address City State Aide Telephone Number Social Security Number* RHHA Registration Number CNA Registration Number II. Record Competency/Skills Check County ZIP code Date of Hire Date of Birth

Name of Organization Conducting Check City, State and ZIP code Facility Number Supervisor's Name Conducting Check Date Completed III. Agency Identification

Program Director's Name Name of Home Health Agency Street Address City Facility Number Agency Telephone Number ____________________________________ Program Director's Signature __________________ Date County ZIP Code