Get As Required By Indiana Code 16-37-1 The Indiana State Department Of Health Has Implemented The

This guide provides clear instructions for users on how to fill out the User Agreement form required by Indiana Code 16-37-1. By following the outlined steps, users will ensure successful registration to access the Indiana Birth Registration System, Indiana Death Registration System, and Indiana Fetal Death Registration System.

Follow the steps to complete your User Agreement form

1. Click ‘Get Form’ button to access the User Agreement form and open it for completion.
2. Indicate your type of account at the specified section of the form. Choose either 'new user' or 'modify account access' based on your situation. If modifying, provide your current User ID.
3. Check the box for the relevant system(s) to which you need access: Indiana Birth Registration System, Indiana Death Registration System, or Indiana Fetal Death Registration System.
4. Print your legal name in the designated area for identification purposes, followed by your signature.
5. Include your State issued Operator License or State ID number and the state that issued it, along with your date of birth.
6. Enter your Indiana professional licensing number if applicable, and its expiration date.
7. Provide your email address for confirmation and future notifications regarding system activities related to your access.
8. List each facility location where you will be accessing the system. Provide necessary details like facility name, address, county, and phone number.
9. Specify the office manager's name and signature to verify their identification for password resets.
10. Check the roles you will play in completing the records at the listed locations, ensuring to select all that apply.
11. Once all required fields are completed, send the completed form to the Indiana State Department of Health or fax it to the provided number.
12. You will receive an email confirmation within twenty-four hours. If you do not receive it, or have questions, contact the VR Helpdesk.

Complete your User Agreement form online to gain access to vital registration systems.