Physician Certification for Long-Term Care Services

for facilitating completion of State Form 38143 (R5/6-93) form 450B/PASARR2/450B
Indiana Family and Social Services Administration (IFSSA)

Current dates of signed and uploaded Form 450B submissions being worked in the Division of Aging:

Assessment TypeDateSubmissions
request for continued stay (Division of Aging)07/01/201513 
Medicaid effective date (Division of Aging)05/26/20151195 
nursing facility transfer (PAS) (Division of Aging)05/28/2015212 
nursing facility transfer (PASRR) (Division of Aging)05/29/201553 
PAS/PASRR not completed (Division of Aging)07/01/2015
Computer-Generated 450B SA/DE05/19/20151302 

Submissions that have had more information requested are not included, as they are already in process

Please click here if you are having problems uploading, or if you receive a notification that your uploaded documents were not transmitted to the Division of Aging in the correct format. (Revised 11/1/2013)

Effective January 21, 2014, computer-generated 450B SA/DE forms will be e-mailed directly to nursing facilities, instead of using the postal service. Please note these will be secured emails from The following is an example of what you might see:

Subject: Division of Aging 450B SA/DE - Screening xx xxxxx has created a secure e-mail message for you at:

To access your message, simply follow these steps:

1. Click on the above link.
2. Type in your e-mail address for your Login ID, and then your password.
3. Access your Inbox to view your message.

Please select a task

Check the status of a Form 450B submission online

Fill out a new Form 450B

Upload a signed Form 450B

Upload additional documentation for a Resident Summary

NEW Request a duplicate Form 450B ONLINE

Reference Materials