Get In State Form 49560 2018-2026

Filling out the IN State Form 49560 is a crucial step for individuals seeking to register as home health aides in Indiana. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Home Health Aide Registry Application

1. Use the ‘Get Form’ button to access the form and open it in your preferred digital environment.
2. In Section I, enter the full name of the home health aide, date of birth, residential street address, city, county, ZIP code, telephone number, and Social Security number. Ensure all information is typed or printed legibly.
3. Proceed to Section II, where you will provide details about the agency, third party, or educational institution conducting the competency evaluation. Include the address, city, ZIP code, county, facility number (if applicable), the name of the registered nurse conducting the evaluation, their professional license number, and the date the evaluation was completed.
4. In Section III, fill out the employer's details, including the name of the employer, address, city, telephone number, county, and ZIP code. Include the name of the administrator.
5. Move to Section IV, where the home health aide applicant must provide their signature and date, affirming the accuracy of the information provided. The registered nurse conducting the competency evaluation must also sign and date their section, followed by the employing administrator's signature and date.
6. Finally, review all completed sections for accuracy. You can then save the changes, download the form, print it, or share it as needed.

Complete your Home Health Aide Registry Application online today!