PASRR Level I and Level II Documentation

Pre-admission screening form to document PASRR Level I completion and, when indicated, Level II review for mental illness or intellectual disability prior to skilled nursing placement.

Submission Overview

• Submission Date
• Facility Name
• Completed By
• Role / Title
• Submission Type

Resident Screening Details

• Resident Initials
• Date of Birth
  Collect only if needed to accurately match the resident record.
• Is the individual a Medicaid applicant or beneficiary?
• Planned or Actual Admission Date
• Admission Source

Level I Screening

• Was Level I screening completed?
• Level I Completion Date
• Level I Result
• Level I Summary / Basis for Determination
  Briefly document the observable facts or record sources used to support the Level I result.

Level II Review

• Was Level II review referred?
• Referral Date
• Reviewing Entity
• Level II Determination
• Level II Summary / Outcome Notes

Admission Disposition

• Final Disposition
• Disposition Notes
• Supporting Documents
  Upload any supporting PASRR documentation, determinations, or referral records.

Attestation and Consent

• I attest that the information provided is accurate and complete to the best of my knowledge.
• I understand this form may contain limited PII necessary for PASRR documentation and consent to its storage and processing for compliance purposes.
• Electronic Signature
• Signature Date