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)04/27/2016
Medicaid effective date (Division of Aging)04/26/2016119 
nursing facility transfer (PAS) (Division of Aging)04/26/201631 
nursing facility transfer (PASRR) (Division of Aging)04/28/2016
PAS/PASRR not completed (Division of Aging)04/29/2016
Computer-Generated 450B SA/DE04/28/201664 

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)

PLEASE NOTE

The current PAS regulations will no longer be in effect as of June 30, 2016. To stay abreast of the changes effective July 1, 2016, please register here to receive ongoing updates from the Division of Aging.


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 DA.NFinforequest@fssa.in.gov
  • 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