Form Fa-18 Pre-Admission Screening Resident Review (Pasrr) Level 1 Identification Screening
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4Hewlett Packard Enterprise - Nevada Medicaid and Nevada Check Up
Pre-admission Screening Resident Review (PASRR) Level 1 Identification Screening
Fax to: (855) 709-6847
Questions? Call: (800) 525-2395
DATE SUBMITTED:
SCREENING TYPE:
Initial (PAS)
Resident Review (RR) - Initial Date:
RECIPIENT INFORMATION
Name:
Recipient ID (if Medicaid eligible):
Gender:
Male
Female
Home Address (not a P.O. box):
Phone:
Date of Birth:
Social Security Number:
Marital Status:
Married
Single
Divorced
Widowed
Translator Required - Language:
Known Diagnoses (codes or descriptions):
Other Insurance Name:
Other Insurance ID#:
Where is the recipient currently located?
Home
Inpatient Acute Care
ER/Observation
Group Home/Assisted Living
Nursing Facility
Rehabilitation/Hospital
Other - specify:
On what date will the recipient be going into the Nursing Facility? (Enter date if known.)
RESPONSIBLE PARTY INFORMATION (required if recipient has indicators of MI, MR/RC)
Name:
Phone:
Address:
Relationship to Recipient:
ATTENDING PHYSICIAN INFORMATION (required if recipient has indicators of MI, MR/RC)
Name:
Address:
Phone:
Fax:
NPI:
REQUESTING FACILITY OR PROVIDER INFORMATION
Name:
Address:
Phone:
Fax:
NPI:
Contact Name:
Professional Title:
The person completing this form attests that the individual (or appropriate family and/or guardian) has been informed that
he/she is being considered for Nursing Facility placement.
Name and Professional Title of Person Completing this Form:
Date Completed:
ADMITTING FACILITY INFORMATION (if known)
Name:
Address:
Phone:
Fax:
NPI:
Contact Name:
Contact Phone:
SECTION 1: MENTAL ILLNESS (MI) SCREENING
1A. Psychiatric Diagnosis (Check each disorder that applies.)
Bipolar
Delusional
Major Depression
Psychotic
Schizoaffective
Schizophrenia
Severe Anxiety/Panic
Somatoform
Eating–specify: __________________________
Personality–specify: ____________________________
Other–specify: ___________________________________________________________________________________________
1B. Current Psychiatric Medications
Diagnosis/Purpose of Medication
1. _______________________________
___________________________________________________________________
2. _______________________________
___________________________________________________________________
3. _______________________________
___________________________________________________________________
No
Hewlett Packard Enterprise Use Only: Meets diagnosis criteria f or chronicity?
Yes
FA-18
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PASRR Level 1 Identification Screening - Please Print or Type
11/05/12
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