Get Administrator Or Director Of Nursing Change Form ... - In

Filling out the Administrator or Director of Nursing Change Form is an essential step in notifying the Indiana State Department of Health about changes in leadership within your facility. This guide provides a clear, step-by-step process to assist users in completing the form online efficiently.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering your facility number in the designated field. Ensure that the number corresponds accurately to your facility's registration.
3. Input your facility name in the next section. This should be the official name recognized by the Indiana State Department of Health.
4. Fill in the street address, city, state, and zip code for your facility. Double-check each entry to avoid any errors.
5. In the section labeled 'Please Check the Appropriate Box,' select the relevant position change type. Choose either 'Administrator (New)' or 'Director of Nursing (New)' as applicable.
6. Provide the name of the individual being appointed to the respective position and include their license number.
7. Enter the date they were appointed to the position. This information should reflect the official date of change.
8. Include the email address of the new administrator or director of nursing for further communication.
9. If you are indicating a previous position holder, fill out their name, license number, and last date in the position in the corresponding fields for clarity.
10. Once all sections are completed, review the entire form for accuracy and completeness.
11. You can now save changes to the form, or choose to download, print, or share it as needed.

Complete the Administrator or Director of Nursing Change Form online today.