PASRR LEVEL I SCREEN - KePRO

PASRR LEVEL I SCREEN . DETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, AND OTHER RELATED CONDITIONS. IF YOU NEED ASSISTANCE WITH COMPLETING THIS FORM OR HAVE GENERAL QUESTIONS ABOUT PASRR , PLEASE CALL KePRO AT 1-833-525-5784. All LEVEL II Assessment decisions or deferral/waiver of a LEVEL II Assessment must be made by KePRO , a designee of the Maine Department of Health & Human Services (DHHS). PLEASE SUBMIT ALL PAGES, INCLUDING THE SIGNED ATTESTATION ON PAGE 4. 1. SUBMITTING HOSPITAL/AGENCY INFORMATION. HOSPITAL/AGENCY NAME DATE. FAX NUMBER PHONE NUMBER. PRINT NAME/LICENSURE/TITLE OF PERSON COMPLETING FORM. 2. CONSUMER INFORMATION. LAST NAME FIRST NAME DATE OF BIRTH SOCIAL SECURITY NUMBER. MAINECARE NUMBER MEDICARE NUMBER OTHER PAYER SOURCE. HOME STREET ADDRESS TOWN, STATE, ZIP CODE PHONE. 3. EMERGENCY CONTACT INFORMATION.

pasrr level i screen determination for mental illness, intellectual disability, and other related conditions page 1kepro fax 844-356-7500 of 4 meassess.kepro.com effective: 1/11/18 if you need assistance with completing this form or have general questions about pasrr,

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