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State of Florida Agency for Health Care Administration Pre-Admission Screening and Resident Review PASRR Level I Screening for Serious Mental Illness SMI / Intellectual Disability or Related Conditions ID Use for Medicaid Certified Nursing Facility NF Only Present Location of Individual Being Evaluated NF Hospital Home -- SSN DOB mm/dd/yyyy Male Name of Individual Being Evaluated print Age Female Street Address City Assisted Living Facility State Zip Group Home Other Individual s or Residency Phone Number // Legal Representative s Name if applicable Representative s Phone Number // Screening Date mm/dd/yyyy Medicaid Number if Applicable Other Health Insurance Name and Number if Applicable WHY ARE WE ASKING FOR YOUR SOCIAL SECUITY NUMBER Federal law permits the State to use your social security number for screening and referral to programs or services that may be appropriate for you 42 CFR 435. 910. You do not have to fill in your Social Security number but if you do it will remain confidential and protected under penalty of law. We will not use it or give it out for any other reason unless you have signed a separate consent form that releases us to do so. State of Florida Agency for Health Care Administration Pre-Admission Screening and Resident Review PASRR Level I Screening for Serious Mental Illness SMI / Intellectual Disability or Related Conditions ID Use for Medicaid Certified Nursing Facility NF Only Present Location of Individual Being Evaluated NF Hospital Home -- SSN DOB mm/dd/yyyy Male Name of Individual Being Evaluated print Age Female Street Address City Assisted Living Facility State Zip Group Home Other Individual s or Residency Phone Number // Legal Representative s Name if applicable Representative s Phone Number // Screening Date mm/dd/yyyy Medicaid Number if Applicable Other Health Insurance Name and Number if Applicable WHY ARE WE ASKING FOR YOUR SOCIAL SECUITY NUMBER Federal law permits the State to use your social security number for screening and referral to programs or services that may be appropriate for you 42 CFR 435. 910. You do not have to fill in your Social Security number but if you do it will remain confidential and protected under penalty of law. We will not use it or give it out for any other reason unless you have signed a separate consent form that releases us to do so. Section I Nature of the Request for PASRR Level I Screening Request for admission to an NF Resident Review of an individual already residing in an NF Significant Physical Change Improvement Decline New Suspicion of SMI or ID SMI ID SMI and ID Significant Mental Change AHCA MedServ Form 004 Part A Effective September 2014 Section II PASRR Screen Decision-Making SMI or suspected SMI check all that apply ID or suspected ID check all that apply Anxiety Disorder Bipolar Disorder Depressive Disorder Dissociative Disorder Panic Disorder Personality Disorder Psychotic Disorder Schizoaffective Disorder Schizophrenia Somatic Symptom Disorder Other specify Substance Abuse Autism Cerebral Palsy Down Syndrome Epilepsy Intellectual Disability with an IQ lower than 70 specify Prader-Willi Syndrome Spina Bifida Age of onset for intellectual disability Years If known* Finding is based on Documented History Medications Behavioral Observation Individual Legal Guardian or Family Report Additional Information If any of the above items are checked a Level II evaluation must be completed* Other Indications for PASRR Screen Decision-Making 1.