New Jersey Department of Human Services

Division of Aging Services

P.O. Box 807

Trenton, NJ 08625-0807

Notice of Referral for

Level II Pre-Admission Screening and

Resident Review (PASRR) Evaluation

CONSUMER INFORMATION
Name of Consumer

Date

Address of Consumer

REFERRING PROVIDER / AGENCY / PROGRAM INFORMATION
Name of Provider/Agency/Program

Street Address

Telephone Number

City, State, Zip Code

Fax Number

Attention:
(Name)
Check One: Consumer Authorized Representative

Preadmission Screening Resident Review (PASRR) Federal Regulation CFR 483.106 requires that individuals must be assessed prior to placement in a Medicaid Certified Nursing Facility to identify individuals with a Serious Mental Illness and/or Intellectual disability, or related condition to determine if the individual requires any specialized services for the condition(s) as checked below. This evaluation ensures that the individual is placed in the most appropriate setting for their needs; whether in the community or in a Nursing Facility. A review of clinical documentation for the above-named individual indicates evidence of the following conditions (screener please check all that apply) and a referral has been made to the indicated authority for a Level II PASRR evaluation and determination:

Serious Mental Illness; Division of Mental Health and Addictions Services (DMHAS),

Requirement: Psychiatric Evaluation Form completed by an independent or treating physician

Intellectual Disability; Division of Developmental Disabilities (DDD)

Requirement: DDD Intake Application completed by consumer/authorized representative

Related Condition (Developmental Disability); Division of Developmental Disabilities

Requirement: DDD Intake Application completed by consumer/authorized representative

Your application for clinical eligibility and admission to a Nursing Facility cannot be processed until the Level II PASRR evaluation and determination are completed. Failure to comply with the requirements of DMHAS/DDD will prohibit the approval of clinical eligibility for admission to a nursing facility. Questions should be referred to the Department of Human Services, Division of Mental Health and Addiction Services at 1-800-382-6717 and/or the Department of Human Services, Division of Developmental Disabilities at 1-800-832-9173.

Name of Level I Screening Professional (Print)

Title of Screening Professional

Signature of Screening Professional

Date of Referral to Level II Authority(ies)

LTC-29

FEB 19

-2-

LTC-14B

NOV 00

LTC-29, Referral Notice / Level II Evaluation

LTC-29, referral, Level II evaluation, LTC, aging services, mental illness, mental regardation, developmental disability

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2019-01-07

human services