Indiana Administrative Code
Title 470 - DIVISION OF FAMILY RESOURCES
Article 11.1 - HOSPITAL CARE FOR THE INDIGENT
Rule 2 - Hospitalization, Financial Assistance and Covered Services; Patient Data
Section 2-3 - Collection of data; recipient profile

Universal Citation: 470 IN Admin Code 2-3

Current through September 18, 2024

Authority: IC 12-13-2-3; IC 12-13-5-3

Affected: IC 12-16

Sec. 3.

(a) Each county office of family and children shall submit to the division of family and children within sixty (60) days following disposition of patient's application for eligibility, on forms prescribed by the division of family and children, information concerning the patient, which shall include, but not be limited to, the following:

(1) Name.

(2) County and state of residence.

(3) Welfare/SSI status.

(4) Age.

(5) Race.

(6) Sex.

(7) Household status.

(8) Employment.

(9) Household income.

(10) Reason for care.

(11) Diagnosis.

(12) Status of application.

(b) Any provider seeking reimbursement under the above-noted patient's application shall assist the county office of family and children in completing the required forms by submitting that information which is not available to the county office of family and children.

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