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Get MA PAS-1 2006-2024

T source, are admitted to a nursing facility. This form must be kept permanently in the resident’s medical record. A licensed nurse or licensed social worker employed by the nursing facility must complete both sides of this form before the applicant’s admission, as mandated by the federal Omnibus Budget Reconciliation Act (OBRA) of 1987. Nursing Facility Provider Information Nursing Facility Applicant Information Provider number MassHealth ID or SSN Name Name Address Address City, Z.

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