Pre admission evaluation tennessee 2026

1. Click ‘Get Form’ to open the pre admission evaluation tennessee in the editor.
2. Begin with the AUTHORIZATION section, which is for TennCare use only. This will be completed by TennCare staff after your submission.
3. In SECTION I, GENERAL INFORMATION, select the type of services requested: either 'ICF/MR' or 'HCBS-MR'. Ensure you provide accurate details about the provider's name, address, and phone number.
4. Proceed to indicate the REASON FOR PREADMISSION EVALUATION by checking the appropriate box.
5. Fill out RECIPIENT INFORMATION with the applicant’s personal details including name, address, sex, date of birth, age, telephone number, Medicaid ID number, and social security number.
6. In SECTION II, PSYCHOLOGICAL EVALUATION, check the level of mental retardation and enter IQ test scores as required. Attach a psychological examination report if necessary.
7. Complete SECTION III by assessing capabilities and needs. Provide detailed responses for each assessment perimeter and include any necessary documentation for behavior intervention.
8. Finally, in SECTION IV, MEDICAL EVALUATION, list applicable diagnoses and current medications. Ensure that all signatures are provided where required before submitting your form.

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