Patient Information Request
As the next step in the state’s COVID-19 immunization program, the Indiana Department of Health will reach out patients with comorbidities that indicate they are more likely than others to become severely ill from COVID-19 and offer them COVID-19 immunization. We are asking you to provide contact information for your patients with the following conditions:
• Active dialysis
• Sickle cell disease
• Down syndrome
• Post-solid organ transplant
• People who are actively in treatment (chemotherapy, radiation, surgery) for cancer now or in the last three months, or with active primary lung cancer or active hematologic cancers (lymphoma, leukemia and multiple myeloma)
• Intellectual and Developmentally Disabled individuals receiving home/community-based services. (FSSA to provide patient information for this community.)
• Early Childhood Conditions that are Carried into Adulthood:
   o Cystic Fibrosis
   o Muscular Dystrophy
   o People born with severe heart defects, requiring specialized medical care.
   o People with severe type 1 diabetes, who have been hospitalized in the past year.
   o Phenylketonuria (PKU), Tay-Sachs, and other rare, inherited metabolic disorders.
   o Epilepsy with continuing seizures, hydrocephaly, microcephaly, and other severe neurologic disorders
   o People with severe asthma, who have been hospitalized for this in the past year.
   o Alpha and beta thalassemia
   o Spina bifida
   o Cerebral palsy
• People who require supplemental oxygen and/or tracheostomy
• Pulmonary fibrosis, Alpha-1 Antitrypsin
• Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, combined primary immunodeficiency disorder, HIV, daily use of corticosteroids, use of other immune weakening medicines, receiving tumor necrosis factor-alpha blocker, or rituximab.
• Pregnancy
• Other

Individual patient health information (PHI) may be shared with the Department of Health without the consent of the patient through the Treatment exception in HIPAA, found at 45 CFR 164.506. This is a referral for treatment, the treatment is the vaccination, from one provider to another. The Department of Health is a provider for purposes of vaccine administration.

Please begin by entering your license number below.

Provider License Number: