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Get Colorado Pasrr Form

Gender: c Male c Female Race: c Caucasian c African American c Asian c Hispanic c Other: Current Location: c*Medical Facility c*Psychiatric Facility c *Nursing Facility c Community c Other: *Provide Admission Date: Receiving Nursing Facility: Receiving Nursing Facility Address: City: State: Zip: Payment Method: c Medicare c Private Pay c Medicaid c Medicaid Pending c Medicaid # c Hospice c PACE c 30 Day PACE Respite ** Provide ULTC Scores if Medicaid or Medicaid Pending: Bathing Dressing .

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