An Services Level I Screening (Revised 3-22) SECTION 1 LEVEL I SCREENING PAS ARR Change in Condition Hospital Exempted Discharge SECTION 2 PATIENT, LEGAL REPRESENTATIVE AND AGENCY INFORMATION Patient Name (First, MI, Last) Date of Birth (MM/DD/YY) Gender Male Address (number, street, apt., or lot #) City County of Residence State Social Security Number Medicaid Beneficiary ID Number Female Zip Code Medicare ID Number Does this patient have a court-appointed guardian If yes,.
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How to fill out the MI DHHS DCH-3877 online
The MI DHHS DCH-3877 form is essential for identifying individuals who may require mental health services upon admission to a nursing facility. This guide provides step-by-step instructions to help users complete the form accurately and efficiently online.
Follow the steps to fill out the MI DHHS DCH-3877 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with Section 1 where you need to indicate if this is a Preadmission Screening (PAS) or an Annual Resident Review (ARR) by checking the appropriate box and noting any change in condition or hospital exempted discharge.
- In Section 2, provide the patient’s information, including their name, date of birth, gender, address, and social security number. Make sure to fill in all required fields accurately to avoid delays.
- Indicate whether the patient has a court-appointed guardian or another legal representative. If yes, provide their details, including name, county, and contact information.
- Complete the referring agency and nursing facility information, including names, addresses, and telephone numbers as necessary for processing.
- Proceed to Sections 3 and 4, which must be completed by a qualified clinician. Ensure that all six screening criteria are addressed and that accurate information regarding the patient's mental health diagnosis and treatment is provided.
- Clinicians should review the criteria and confirm all responses. Section 4 requires clinician certification, so ensure their signature, date, and license details are correctly entered.
- Once the form is fully completed, users can save changes, download, print, or share the form as needed for submission to the appropriate agency.
Complete the MI DHHS DCH-3877 form online today to ensure timely processing for admission.
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