Physician Certification for Long-Term Care Services

for facilitating completion of State Form 38143 (R5/6-93) form 450B/PASARR2/450B
DIVISION OF AGING
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)03/12/2014209 
Medicaid effective date (Division of Aging)01/24/20142284 
nursing facility transfer (PAS) (Division of Aging)02/07/2014380 
nursing facility transfer (PASRR) (Division of Aging)02/10/2014104 
Medicaid waiver to nursing facility (Division of Aging)03/18/201415 
PAS/PASRR not completed (Division of Aging)03/12/2014143 

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. (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 FSSA.pasmail@fssa.in.gov. The following is an example of what you might see:

Subject: Division of Aging 450B SA/DE - Screening xx xxxxx

fssa.pasmail@fssa.in.gov has created a secure e-mail message for you at: https://certifiedmail.in.gov/l.aspx?l=en-us&cmid=c5a03d97-de8e-4343-8af6-0c6622fea9f7

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

Reference Materials