STATE OF HAWAII Department of Human Services PATIENT'S NAME: (Last Name, First, M.I.) PREADMISSION SCREENING ANNUAL RESIDENT REVIEW (PAS/RR) LEVEL I SCREEN PART A: 1. SERIOUS MENTAL ILLNESS (SMI):.
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How to fill out the 1178 Form online
The 1178 Form, part of the Preadmission Screening Annual Resident Review, is essential for determining eligibility for nursing facility services. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring users can efficiently navigate the process.
Follow the steps to fill out the 1178 Form online.
- Click the ‘Get Form’ button to access the online version of the 1178 Form and open it in your browser.
- Begin filling out the form by entering the patient’s name in the designated field. Ensure you format it as Last Name, First, M.I.
- Indicate the referral source by entering the name of the physician or facility that referred the patient.
- In Part A, assess if the individual meets the criteria for Serious Mental Illness (SMI). Answer 'Yes' or 'No' for each question and provide any necessary details.
- In Part B, evaluate for Mental Retardation/Developmental Disabilities (MR/DD) by responding to the questions with 'Yes' or 'No' and ensuring all supporting information is accurate.
- If any answers in Parts A or B are affirmative, proceed to Part C. Answer the questions in this section regarding specific circumstances and check only one option at the bottom.
- After completing the form, review all entries for accuracy and completeness before signing and dating the form in the designated area.
- Once finalized, you can save your changes, download the completed form, print it, or share it as needed.
Complete your 1178 Form online today to ensure timely processing of your application.
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