Morbid Obesity Information
Forms
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)
Submit the completed forms via fax or mail to:
Kristy Holzhausen
Indiana State Department of Health
2 North Meridian Street, 3D
Indianapolis, Indiana 46204 317.233.7378 Fax
Links
- Law concerning "Reporting Deaths or Complications From Morbid Obesity Surgeries"
- Reporting Rule
- FAQ's
Contact Information
For medically related questions, legal requirements, and/or coding issues, please contact:
Elizabeth Hamilton-Byrd, M.D.
Medical Epidemiologist
317.233.7542
E-mail: ebyrd@isdh.in.gov
Note: There is no need to hold completed forms until the mandated submission dates. Completed forms may be submitted to the Indiana State Department of Health at any time before the required dates of June 30 and December 31.
For questions related to administrative processing of forms, options for submission, and/or other non-medical questions, please contact:
Kristy Holzhausen
Indiana State Department of Health
2 North Meridian Street, 3D
Indianapolis, Indiana 46204
317.233.7416 Phone
317.233.7378 Fax
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