State Form 56522 "Abortion Complication Report" - Indiana

What Is State Form 56522?

This is a legal form that was released by the Indiana State Department of Health - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Indiana State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of State Form 56522 by clicking the link below or browse more documents and templates provided by the Indiana State Department of Health.

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Download State Form 56522 "Abortion Complication Report" - Indiana

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ABORTION COMPLICATION REPORT
PLEASE CHECK IF AN AMENDED FORM:
State Form 56522 (R / 7-18)
INDIANA STATE DEPARTMENT OF HEALTH – VITAL RECORDS
Mail completed form to:
Indiana State Department of Health
per IC 16-34-2
P. O. Box 7125
Indianapolis, IN 46204
Abortion Complication Reports for all patients shall be mailed to the Indiana State Department of Health at the above address.
Each failure to file this report on time, as required, is a Class B misdemeanor per IC 16-34-2-4.7(j)
Facility name
City or town of abortion complication
County of abortion complication
If facility is not a hospital or clinic, please enter address. (number and street, city, state, and ZIP code)
Patient’s age
Date of pregnancy termination (month, day, year)
Date of abortion complication (month, day, year)
Race (Select one or more.)
American Indian, Alaska Native, or Asian
Declined to state
White
Ethnicity
Black or African American
Native Hawaiian or Other Pacific Islander
Multiracial
Other
Hispanic or Latino
Not Hispanic or Latino
Patient’s county of residence
Patient’s state of residence
Method of termination obtained by patient
If medication was used to terminate the pregnancy, was medication obtained by a mail
order or internet source?
Yes
No
Not Disclosed
Name of facility where the termination was performed
If medication was obtained by mail order or internet source, please list the source.
Name of medication(s) used for termination, if any
Did you perform the termination for the named patient?
Was this complication previously managed by the abortion provider or abortion provider’s backup physician?
Yes
No
Yes
No
Please list each diagnosed abortion complication and, for each, provide the information required by IC 16-34-2-4.7.
Was this an initial visit by this patient or a follow up visit?
Initial visit:
Yes
No
Follow up visit:
Yes
No
Date(s) (month, day, year) of each follow up visit, if any:
Signature of physician
Full name of physician
Address of physician (number and street, city, state, and ZIP code)
DATE RECEIVED BY ISDH
:
(month, day, year)
Reset Form
ABORTION COMPLICATION REPORT
PLEASE CHECK IF AN AMENDED FORM:
State Form 56522 (R / 7-18)
INDIANA STATE DEPARTMENT OF HEALTH – VITAL RECORDS
Mail completed form to:
Indiana State Department of Health
per IC 16-34-2
P. O. Box 7125
Indianapolis, IN 46204
Abortion Complication Reports for all patients shall be mailed to the Indiana State Department of Health at the above address.
Each failure to file this report on time, as required, is a Class B misdemeanor per IC 16-34-2-4.7(j)
Facility name
City or town of abortion complication
County of abortion complication
If facility is not a hospital or clinic, please enter address. (number and street, city, state, and ZIP code)
Patient’s age
Date of pregnancy termination (month, day, year)
Date of abortion complication (month, day, year)
Race (Select one or more.)
American Indian, Alaska Native, or Asian
Declined to state
White
Ethnicity
Black or African American
Native Hawaiian or Other Pacific Islander
Multiracial
Other
Hispanic or Latino
Not Hispanic or Latino
Patient’s county of residence
Patient’s state of residence
Method of termination obtained by patient
If medication was used to terminate the pregnancy, was medication obtained by a mail
order or internet source?
Yes
No
Not Disclosed
Name of facility where the termination was performed
If medication was obtained by mail order or internet source, please list the source.
Name of medication(s) used for termination, if any
Did you perform the termination for the named patient?
Was this complication previously managed by the abortion provider or abortion provider’s backup physician?
Yes
No
Yes
No
Please list each diagnosed abortion complication and, for each, provide the information required by IC 16-34-2-4.7.
Was this an initial visit by this patient or a follow up visit?
Initial visit:
Yes
No
Follow up visit:
Yes
No
Date(s) (month, day, year) of each follow up visit, if any:
Signature of physician
Full name of physician
Address of physician (number and street, city, state, and ZIP code)
DATE RECEIVED BY ISDH
:
(month, day, year)