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DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-22191 Rev. 08/2008 STATE OF WISCONSIN PREADMISSION SCREEN AND RESIDENT REVIEW PASARR LEVEL I SCREEN This form is required under sections 42 USC 1936r b 3 F and 1396r e 7. Is there a diagnosis or history of mental retardation illness that results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons a.

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