IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

Amber Alert
Amber Alert - TEST

Indiana State Department of Health

ISDH Home > Health and Human Services > Morbid Obesity Information Morbid Obesity Information

Forms

As of October 1, 2009, the Indiana State Department of Health will no longer be able to accept the paper versions of State Form 53321 (Surgery for the Treatment of Morbid Obesity – Initial Report) and State Form 53322 (Surgery for the Treatment of Morbid Obesity – Follow-up Report).

To request access to our web-based reporting system, please complete the User’s Access Sheet and email it to MODE@state.in.us

Surgery for the Treatment of Morbid Obesity - Initial Report (State Form 53321)

Surgery for the Treatment of Morbid Obesity - Follow-up Report (State Form 53322)

Links

Note: There is no need to delay reporting until the mandated submission dates.  Reports can be submitted to the Indiana State Department of Health online via the Gateway system at any time before the required dates of June 30 and December 31.

Contact Information

Kristy Holzhausen
Indiana State Department of Health
2 North Meridian Street, 3D
Indianapolis, Indiana 46204
317.233.7416 Phone
317.233.7378 Fax
E-mail: mailto:MODE@isdh.in.gov