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Ltc-14 - Level I Screening For Mental Illness (Mi) / Intellectual Disability (Id) / Related Condition (Rc) Page 2

This Level I Screening Form must be completed prior to admission into a Medicaid Certified Nursing Facility. Failure to complete this form accurately may result in Medicaid Recoupments.

PLEASE PRINT

State of Alabama Department of Mental Health

LTC-14 Rev. 11

Level I Screening for Mental Illness (MI) / Intellectual Disability (ID) / Related Condition (RC)

Page 2 of 2

Use for Medicaid Certified Nursing Home (NH) Only

Select Long Term Care or the applicable Short Term Care Option:



Long Term Care

Short Term Care with the intent to return to the community after:



Convalescent Care-Applicable for patients with or without MI/ID/RC diagnoses

For MI/ID/RC patients (1) you must have PT and/or OT orders as prescribed by a physician for 5x a week for 120 days or less (2) is not a danger to self

or others and (3) must be currently in the hospital w/ a direct admission into the NH.

 Respite for no more than 7 days & is not a danger to self or others (Respite is not reimbursed by Medicaid under the NH Program)

 NH admission for an emergency situation requiring protective services by DHR, person can not be a danger to self or others, if admission will

exceed 7 days, the OBRA office must be contacted immediately to prevent non-compliance

(Not applicable if currently in a hospital or other protective

environment)

 Other Short Term Stay (If applicable, persons with MI/ID/RC must have the Level II completed prior to admission)



 IV Therapy

 Wound Care

 Diabetes Care

 Home (in community) Convalescent Care

 Other (please specify) ________________________________________________________ 

8. Is this individual terminally ill (life expectancy of six months or less), comatose, ventilator dependent, functioning at brain stem level or diagnosed as

having Cerebella Degeneration, Advanced ALS, or Huntington’s Disease as certified by an MD?  Yes  No