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)02/10/201614 
Medicaid effective date (Division of Aging)02/08/201664 
nursing facility transfer (PAS) (Division of Aging)02/10/2016
nursing facility transfer (PASRR) (Division of Aging)02/11/2016
PAS/PASRR not completed (Division of Aging)02/11/2016
Computer-Generated 450B SA/DE02/11/201615 

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 per the memo of August 20, 2015

  • All emails regarding Electronic 450B issues (except requests for a duplicate Form 450B) should be sent to
  • Click here to request a duplicate Form 450B. Please use this utility instead of calling or emailing for a duplicate.
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