Printable level of care passr 2025

1. Click ‘Get Form’ to open the printable level of care passr in the editor.
2. Begin by filling out Section A: Patient Information. Enter the patient's name, date of birth, AHCCCS ID number, and address where the patient is currently located.
3. In Section B: Exemptions, carefully circle 'Yes' or 'No' for each question regarding primary and secondary diagnoses related to dementia and convalescent care.
4. Proceed to Sections C and D for Identification of Potential Mental Retardation and Mental Illness. Circle answers based on the patient's medical history as indicated.
5. In Section E: Referral Action, select only one option that applies to the patient’s situation regarding Level II determination.
6. Finally, ensure that both the patient or their representative and a medical professional sign in Sections F and G, providing all necessary details.

Start using our platform today for free to streamline your document editing and form completion!