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Pae form 2026

The document outlines the Pre-Admission Evaluation (PAE) process for individuals seeking care in Intermediate Care Facilities for the Mentally Retarded (ICF/MR) or Home and Community-Based Services (HCBS) waivers. It includes sections for Medicaid decision-making, general information about the recipient, psychological evaluations, assessments of capabilities and needs, medical information, a plan of care for both ICF/MR and HCBS services, and physician certification requirements. The PAE is essential for determining eligibility and necessary services for individuals with developmental disabilities.

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Click ‘Get Form’ to open the PAE form in the editor.
Begin with Section I: General Information. Fill in the provider's name, address, and contact details. Ensure all fields are completed accurately.
In the Reason for Pre-Admission Evaluation section, select the appropriate reason for evaluation by checking the relevant box.
Proceed to Section II: Psychological Evaluation. Enter the level of mental retardation and IQ test score if applicable. Attach any required psychological examination documents.
Move on to Section III: Assessment of Capabilities and Needs. For each capability (bathing, communication, etc.), choose the best answer that reflects the recipient's abilities.
Complete Sections IV and V with medical information and plan of care details as necessary, ensuring all medications and services requested are listed clearly.
Finally, have a qualified professional sign in Section VI to certify that all information is accurate before submitting your completed form.

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