The 20 Indiana forms clinicians complete, from the workers' comp Physician's Report and BMV certificates to Medicaid prior authorization, sports physicals and the POST.
This page lists the Indiana forms clinicians complete, grouped by program, and each group links to its program hub. On workers' comp claims, the attending physician or an independent medical examiner files State Form 2118, the Physician's Report, with exam findings on page 1 and the impairment rating on page 2. The BMV uses State Form 50018 for impairments that affect driving, State Form 22106 after a failed vision screening and State Form 42070 for disability plates and placards. Indiana Medicaid takes one IHCP Prior Authorization Request Form.
That IHCP form works for fee-for-service and every managed care plan: check the plan on the form and attach records. For commercial insurers, the Department of Insurance has a standard form for services, not drugs. Death certification happens online in DRIVE, and the POST, State Form 55317, stays with the patient. The IHSAA physical needs a handwritten signature and license number. Of these forms, 4 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart; the clinician reviews and signs.
State Form 2118Attending physician's or independent medical examiner's report of examination findings (page 1) and permanent partial impairment rating (page 2).
Physician's statement supporting a TRF member's application for the classroom disability benefit (teacher unable to perform classroom duties).
State Form 22106Eye care professional's certification of visual acuity for an applicant referred after failing the BMV vision screening.
State Form 50018Physician's certificate about a medical impairment affecting the patient's ability to drive, used by the BMV in licensing decisions.
State Form 13226Eye care professional's certification for a driver who uses bioptic telescopic lenses.
State Form 42070Applies for a disability license plate or a permanent or temporary disability parking placard, with a health care provider's certification of the disability.
Universal nonpharmacy prior authorization request accepted by IHCP fee-for-service (Acentra Health) and every managed care entity (Hoosier Healthwise, HIP, Hoosier Care Connect, PathWays).
Physician certification of medical necessity for home oxygen under Indiana Medicaid.
Physician medical clearance documenting the need for a motorized wheelchair purchase under Indiana Medicaid.
State Form 48736Physician certification of terminal illness for the Indiana Medicaid hospice benefit.
History, physical examination and clearance required under IHSAA Rule 3-10 before a student practices, plus the parent consent and release certificate.
Vaccine Medical Exemption Form (Spanish)
Health care provider certification that a student qualifies for a medical exemption from Indiana school immunization requirements.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Electronic registration system in which Indiana medical certifiers complete the cause-of-death certification for death records.
State Form 55317Physician's order for scope of treatment (CPR, interventions, nutrition) for patients with advanced chronic or serious illness under IC 16-36-6.
Online report of suspected neglect, battery or exploitation of an endangered adult to Indiana APS.
State Form 56459Case report of chlamydia, gonorrhea, syphilis and other STDs diagnosed or treated by a provider.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A physician (MD or DO), nurse practitioner or physician assistant. The examiner completes the Physical Examination page and the clearance with a handwritten signature and license number. Stamps and pre-signed forms are not accepted, and the form may not be altered. For the next school year, the exam must be on or after April 1. The form is filed with the school principal and comes in Spanish.
A temporary placard issued on State Form 42070 expires on the date the health care provider sets or after 1 year, whichever comes first. A permanent placard does not expire unless a provider writes to the BMV that the disability is no longer permanent. The provider completes the certification section, and the applicant applies at any BMV branch or by mail. The BMV does not accept prior versions of the form.
Online, in DRIVE (Database Registration of Indiana's Vital Events). The medical certifier, a physician, NP or PA, or the coroner completes the cause-of-death section through an Access Indiana account. The Department of Health lists no paper medical certification form. Getting access takes two steps: an Access Indiana account, then a DRIVE e-request.
The Indiana Health Coverage Programs Prior Authorization Request Form is accepted for nonpharmacy services by fee-for-service (Acentra Health) and every managed care entity: Hoosier Healthwise, HIP, Hoosier Care Connect and PathWays. Check the plan on the form, attach medical documentation and send it by fax or through the Atrezzo provider portal or the plan's portal. A qualified practitioner signs it.