Form Fa-18 Pre-Admission Screening Resident Review (Pasrr) Level 1 Identification Screening Page 4

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PASRR Level I Determination:
PASRR Level II Determination:
IA: Exempted Hospital Discharge
PAS: Applicant to NF
RR: Resident in NF
IA: Qualifies for Categorical Determination
IIE: Time-Limited Approval—Limitation Exp. Date:
IA: Requires PASRR Level II
IIF: Terminal Illness
IB: Has Dementia, Alzheimer’s, Organic Brain Syndrome
IIG: Severe Physical Illness
IC: Not MI, MR/RC or Demented
Referral Needed for PASRR Level II:
Referred for MI—Date Referred: _______________________
Referred for MR/RC—Date Referred: ___________________
Dual Referral MI and MR/RC—Date Referred:
Date Completed:
Reviewer ID:
Reviewer Comments: ______________________________________________________________________________________
FA-18
Page 4 of 4
PASRR Level 1 Identification Screening - Please Print or Type
11/05/12

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