Transcription of Section A - TMHP
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Section A - TMHP
PASRR Level 1 Screening, September, 2017, 1 of 12 DLNI ndividualA0800. 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. Street AddressReferring Entity Information (Screener)A1000A. NameA1000B. Street AddressA1000D. StateA1000E. ZIP CodeA1000F. Phone NumberA1000C. CityA1100. Date of Last Physical ExaminationA1200B.
Personal Information (Individual being screened) B0100A. First Name B0100B. Middle Initial B0100C. Last Name B0100D. Suffix B0200A. Social Security No.
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