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3877 and 3878 forms-2025

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The document outlines the Preadmission Screening (PAS) and Annual Resident Review (ARR) processes for identifying individuals with mental illness, intellectual disabilities, or related conditions in Michigan. It includes sections for patient information, screening criteria to assess mental health status, and certification by qualified clinicians. The form is essential for determining eligibility for nursing facility admission and ensuring appropriate mental health services are provided.

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Click ‘Get Form’ to open the 3877 form in the editor.
Begin by filling out SECTION I with patient information, including name, date of birth, gender, and address. Ensure all fields are accurately completed.
In SECTION II, carefully review each screening criterion. Circle 'Yes' or 'No' for items related to mental illness or dementia based on the patient's current condition.
If any criteria in SECTION II are marked 'Yes', complete the DCH-3878 form for exemption criteria as needed. This is crucial for determining further evaluations.
Finally, ensure that a qualified clinician completes SECTION III by signing and providing their details. This validates the information provided in the form.

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Versions	Form popularity	Fillable & printable
2022	4.5 Satisfied (39 Votes)
2021	4.8 Satisfied (205 Votes)
2019	4.2 Satisfied (69 Votes)
2007	4.6 Satisfied (45 Votes)
2003	4.2 Satisfied (51 Votes)

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