Level I Pasrr Screen And Determination
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3Level I PASRR Screen and Determination
Failure to accurately complete this form prior to admission to a nursing facility (NF) may result in disallowance of
Medicaid payment.
Name: __________________________________________________________DOB: _____________________________
Address: ________________________________________________Social Security Number: ______________________
SECTION I: MI/MR
Answers to the questions on page 3 of this form will assist in making a determination as to whether the
individual has indications of, or a diagnosis of mental illness and/or mental retardation.
Please circle either Yes or No for the following:
Part A – Mental Illness (MI)
Does the individual have indications of, or a diagnosis of a major mental illness as defined in the DSM-
IV R, limited to schizophrenia, mood disorder, severe anxiety disorder, somatoform disorder;
personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic
YES
NO
disability?
If the answer is YES, please answer all the questions on Page 3 to determine major/serious MI.
Part B – Mental Retardation (MR)
Does the individual have indications of, or a diagnosis of mental retardation as defined in the AAMR
Manual or Classification in Mental Retardation or other related conditions such as cerebral palsy,
epilepsy, or any other conditions, including autistic disorders, that are closely related to mental
YES
NO
retardation because it results in impairment of general intellectual functioning or adaptive behavior (42
CFR 435.1010) which manifested prior to the age of 22.
If the answer is YES, please answer all the questions on Page 3 to determine MR or related condition.
If BOTH answers are NO, STOP! This evaluation is complete and no Level II Evaluation is needed. Physician should
sign and date Level I Screen.
Physician Signature:
Date Completed:
Print Physician Name:
Agency:
If any answer in SECTION I is YES, proceed to SECTION II
SECTION II: CATEGORICAL DETERMINATION OF DEMENTIA/RELATED DISORDER
Does the individual have a primary diagnosis of dementia (including Alzheimer’s Disease or a related
YES
NO
condition) or a non-primary diagnosis of dementia with a primary diagnosis that is not a major mental
illness?
If Mental Illness only and answer is YES, STOP! This evaluation is complete and no Level II Evaluation is needed.
Physician should sign and date Level I Screen.
Physician Signature:
Date Completed:
Print Physician Name:
If Mental Illness ONLY and answer is NO, Proceed to SECTION III
If Mental Illness and Mental Retardation or Mental Retardation only, proceed to next question.
Does the individual have a dementia diagnosis that exists in combination with mental retardation or a
YES
NO
related condition (i.e., Epilepsy, Cerebral Palsy, Prader-Willi Syndrome, Autism, Spina Bifida)?
If MR ONLY and answer is YES, STOP! This individual can be admitted or retained in a NF.
A Level II Evaluation is not needed. Physician should sign and date Level I Screen.
Physician Signature:
Date Completed:
Print Physician Name:
If MI and MR OR MR ONLY and answer is NO, proceed to SECTION III
Issued - 06/30/2009
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