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Z204 security clearance form

Dhs 1178 form-2026

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The document outlines the Preadmission Screening Resident Review (PASRR) process for individuals seeking admission to nursing facilities in Hawaii. It includes a Level I screening form that assesses whether an individual has serious mental illness (SMI) or developmental/intellectual disabilities (DD/ID). The form requires information about the patient's mental health history, medications, and specific conditions that may exempt them from further evaluation. The document emphasizes the need for physician signatures and details the criteria for determining eligibility for nursing facility admission.

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Click ‘Get Form’ to open the DHS 1178 form in the editor.
Begin by entering the patient’s name, date of birth, social security number, and Medicaid ID number in the designated fields at the top of the form.
In Part A, assess if the individual meets criteria for Serious Mental Illness (SMI) by selecting 'YES' or 'NO' for each question. Ensure you provide accurate information based on current diagnoses.
Proceed to Part B and indicate whether there is a diagnosis of Developmental Disability/Intellectual Disability (DD/ID) by marking 'YES' or 'NO' as applicable.
If any answers in Parts A or B are 'YES', complete Part C. If all answers are 'NO', sign and date at the bottom of the form.
Finally, ensure that a physician signs and dates the form before submission to confirm accuracy and compliance.

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2013	4.9 Satisfied (484 Votes)

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Dhs 1178 form-2026

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