Free ATTACHMENT 1 - Indiana

TUBERCULOSIS WAIVER REQUEST
State Form 46595 (R2/3-02) Indiana State Department of Health-Division of Long Term Care

CONFIDENTIAL: This document contains patient information of a confidential nature. SECTION I: TO BE COMPLETED BY REQUESTOR _______________________________________________________________________________________________ Name of Facility _______________________________________________________________________________________________ Street Address ________________________________________________ ________________ ____________________________ City Zip Code Telephone Number I hearby request that ___________________________________________________________ be admitted to the above name facility. This patient suffers from confirmed or suspected Tuberculosis, a communicable disease. As

Administrator of the facility, I certify that the facility is capable of providing proper care for this patient, according to the current guidelines published by the Centers for Disease Control. _________________________________ _____________________________________________________________ Date Signature of Administrator

I, ____________________________________, M.D. the Medical Director of the above named facility, request that the patient, who has confirmed or suspected Tuberculosis, be admitted to the facility. _________________________________ ____________________________________________________________ Date Signature of Medical Director I, __________________________________, M.D. the attending physician for the above named facility, request that the patient, who has confirmed or suspected Tuberculosis, be admitted to the facility. _________________________________ _____________________________________________________________ Date Signature of Attending Physician

SECTION II: TO BE COMPLETED BY DIVISION OF LONG TERM CARE

Based upon the requests made on this form, and with the facility's and medical director's assurance that appropriate precautions to deal with the confirmed or suspected Tuberculosis has been taken, I hereby grant a waiver to the facility and give them permission for this patient to be admitted.

_____________________________ _________________________________________________________________ Date Director, Division of Long Term Care Indiana State Department of Health