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Run: PASRR Level I and Level II Documentation

PASRR Level I and Level II Documentation captures the pre-admission screening needed before skilled nursing placement, including the Level I result, any Leve...

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Submission Overview

Submission Date (required)

Facility Name (required)

Completed By (required)

Role / Title (required)

Submission Type (required)

Resident Screening Details

Resident Initials (required)

Date of Birth

Collect only if needed to accurately match the resident record.

Is the individual a Medicaid applicant or beneficiary? (required)

Planned or Actual Admission Date (required)

Admission Source (required)

Level I Screening

Was Level I screening completed? (required)

Level I Completion Date (required)

Level I Result (required)

Level I Summary / Basis for Determination (required)

Briefly document the observable facts or record sources used to support the Level I result.

Level II Review

Was Level II review referred? (required)

Referral Date (required)

Reviewing Entity

Level II Determination

Level II Summary / Outcome Notes

Admission Disposition

Final Disposition (required)

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. (required)

Yes No N/A

I understand this form may contain limited PII necessary for PASRR documentation and consent to its storage and processing for compliance purposes. (required)

Yes No N/A

Electronic Signature (required)

Signature Date (required)

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