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Section A - TMHP

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PASRR Level 1 Screening, September, 2017, 1 of 12DLNIndividualA0800. Position/TitleA0400. Provider StatePASRR Level 1 ScreeningA0600. Date of AssessmentA0700A. First NameA0700B. Middle InitialA0200B. CityA0200D. ZIP CodeA0500. Vendor NPI/APIA0510. CountyA0700C. Last NameA0700D. SuffixA0900B. Other Type of EntityA0900A. Type of EntitySection A1. Acute Care 2. Psychiatric Hospital 3. ICF/IID 4. Family Home 5. Nursing Facility 6. Physician (MD/DO) 7. OtherA0900C. Physician First NameA0900D. Physician Middle InitialA0900E. Physician Last NameA0900F. Physician Suffix A0100. NameSubmitter Information (NF/LA only)A0200A.

Personal Information (Individual being screened) B0100A. First Name B0100B. Middle Initial B0100C. Last Name B0100D. Suffix B0200A. Social Security No.

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