Indiana Adoption Medical History Report (State Form 9966)
Official state formAdoptionForm State Form 9966Free downloadLast verified November 10, 2026
Medical history of an adopted person and the birth family. It is filed with the Clerk of Court in the adoption case, with the petition or within 60 days of it, not with the vital records office. The Clerk sends the original to the State Registrar with the Record of Adoption.
Who can use this form
- Filed in an Indiana adoption proceeding under IC 31-19-2-7.
- The person who signs Section I affirms, under the penalties for perjury, that the medical history is true.
- Section I is confidential and is for the court and the State Registrar only.
What to send with it
- The original form, filed with the Clerk of Court with the petition for adoption or within 60 days of filing it.
- Section I signed, and Section II typed or printed in black ink.
- Extra pages on plain white paper if more room is needed for details.
- No information that could identify any person in the medical history.
Where to send it
- Mail to
- See the form for where to file it.
- State fee
- The form says the Clerk of Court collects a $20 Adoption Medical History Fee in each adoption proceeding.
- Typical processing
- Not provided
- Form revision
- R6/10-24
- Source
- Official government page