Form 004 - Request For Level Ii Pasrr Evaluation And Determination Or Resident Review Form - Florida Medicaid
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1Request for Level II PASRR Evaluation and Determination or Resident Review
Section I: Request Information
Date: _______________________________ Request for:
Initial Level II Evaluation and Determination or
Resident Review
From: __________________________________
Agency: _________________________________ Phone: ______________________
To: ____________________________________
Agency: _________________________________ Phone: ______________________
An indication of, or a diagnosis of, a serious mental illness or mental retardation or related condition was identified on the Level I Pre-
Admission Screen and Resident Review (PASRR) Screen or the Minimum Data Set revealed a significant change in the resident’s mental or
physical condition. The Level II Evaluation and Determination should be completed within 7 to 9 days and returned to Comprehensive
Assessment and Review for Long-Term Care Services (CARES) or Children’s Multidisciplinary Assessment Team (CMAT). The Resident
Review should be completed within 7 to 9 days and returned to the Nursing Facility and CARES. The Level II Reviewer should notify the
individual or legal guardian of the right to appeal the Level II PASRR Determination.
Section II: Individual Information
Name: _______________________________________________________________DOB: ___________________
Current Location: _______________________________________________________________________________
MI/MR Indicator:
MI (Serious Mental Illness)
MR (Mental Retardation)
Both (MI and MR)
Section III: Required Documents for Level II PASRR Evaluation and Determination or Resident Review (Check box for all documents
that are attached)
For Initial Level II for CARES/CMAT:
For Resident Review for Nursing Facility:
Level I PASRR Screen (AHCA MedServ Form 004, Part
Level I PASRR Screen (AHCA MedServ Form 004, Part A)
A)
Relevant Case Notes/Records of Treatment and/or
Evaluations (including psychiatric)/ Medication
Informed Consent Form ( AHCA MedServ 2040, May 2008)
Administration Record (MAR)
Notice of Privacy Practices (DOEA HIPAA Form)
Minimum Data Set (MDS)
Medical Certification for Nursing Facility/Home and Community
Based Services Form (AHCA MedServ-3008 form)
Other Medical Documentation Including Relevant Case Notes or
Records of Treatment/Medication Administration Record (MAR)
Psychiatric Evaluation Forms (DOEA-MH Form 1911-A, Aug 01,
and DOEA-MH Form 1911-B, Aug 01)
DOEA Assessment Instrument (DOEA Form 701B, September
2008)
CMAT Assessment
Section IV: Level II Reviewer
Date of Level II Determination: _________________________
Disposition:
1. Does the individual meet the State definition for mental illness or mental retardation
or a related condition?
Yes
No
2. Are Specialized Services needed?
Yes
No
3. If yes, can these Specialized Services be provided in a nursing facility?
Yes
No
4. Can Specialized Services be provided in the community?
Yes
No
5. If not, is nursing facility placement appropriate?
Yes
No
6. If Specialized Services are needed, attach the care plan of services that are required.
7. If Specialized Services are not needed, attach other service recommendations required to meet identified needs.
Date of Distribution of Level II Evaluation and Determination to: ___________________________
Individual
Nursing Facility
Other: _______________________
Legal Guardian
CARES
Primary Care Physician
CMAT
Signature: ________________________________________________ Title: _______________________________
AHCA MedServ Form 004, Part B, November 2011
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